Sublet Application Form Page 19
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19.
NOTICE TO TENANT
DISCLOSURE OF BEDBUG INFESTATION HISTORY
Pursuant to the NYC Housing Maintenance Code, an owner/managing agent of residential rental property shall
furnish to each tenant signing a vacancy lease a notice that sets forth the property’s bedbug infestation history.
Name of tenant(s):
Subject Premises:
Apt. #:
Date of vacancy lease:
BEDBUG INFESTATION HISTORY
(Only boxes checked apply)
[ ] There is no history of any bedbug infestation within the past year in the building or in any
apartment.
[ ] During the past year the building had a bedbug infestation history that has been the subject of
eradication measures. The location of the infestation was on the
floor(s).
[ ] During the past year the building had a bedbug infestation history on the
floor(s)
and it has not been the subject of eradication measures.
[ ] During the past year the apartment had a bedbug infestation history and eradication measures were
employed.
[ ] During the past year the apartment had a bedbug infestation history and eradication measures were
not employed.
[ ] Other:
.
Signature of Tenant(s):
Dated:
Signature of Owner/Agent:
Dated:
DBB-N (DHCR 10/10)
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