Tenant Harassment Complaint Form Page 2
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4MANAGEMENT COMPANY INFORMATION
Name of Management Company (if known, or different from landlord)
Phone (if known)
Email address (if known)
Street Address (if known)
City/Town
County
State
Zip
ADDITIONAL INFORMATION
(a) Approximate number of apartments in
(b) Date you moved into the apartment:
(c) Date you moved out of the apartment
building:
(if applicable):
(d) Your apartment is
(e) Your building is
(f) Most recent monthly rent:
Rent Controlled
A condo
Rent Stabilized
A Cooperative
(g) Date you complained to the landlord:
(h) Name of Person Contacted
(i) By: Phone
Letter
In-person
Other
(j) Does your building have an active
(k) Have you requested a rent history for your apartment from the New York State
tenants’ association?
Division of Housing and Community Renewal Office of Rent Administration?
Yes
No
Yes
No
(l) Do you receive a public subsidy (example: Section 8 or
(m) Are you the legal tenant?
Senior Citizen Rent Increase Exemption (SCRIE))?
Yes
No
Yes
No
(n) If you reside in New York City, have you complained to the New York City Department of Housing Preservation and
Development (HPD)?
Yes
No
(o) If the building has changed landlords during your residence, please list them in order, starting with first. Use your recollection or
your own records (such as rent checks or receipts) to prepare the list. Feel free to add a page if more space is needed.
Landlord’s Name, Address & Telephone
Period of Ownership (From – To)
Managing Agent’s Name, Address &
Number
Telephone Number
(p) Have you experienced any of the following? (Check as many as apply)
My landlord/management company has:
Offered me money to move out of my apartment
Engaged in what I believe to be disruptive and dangerous construction practices
Taken me to housing court for what I believe are baseless charges
Used what I believe are aggressive tactics to gather information about me (shown up at my door, followed me, gone through my
mail, etc.)
CFB001 - (rev. 12/16)
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Parent category: Legal