Bloomfield Fair Rent Commission Tenant Complaint Form

2. Tenant Name*
4. Tenant Address*
6. City
7. State
8. Zip Code
10. Tenant Preferred Phone Number*
11. Tenant Email Address*
13. Landlord Name*
14. Property Manager / Contact Name*
16. Landlord/Property Manager Address*
18. City
19. State
20. Zip Code
22. Landlord/Property Manager Phone Number
23. Landlord/Property Manager Email Address
25. Description of Residential Unit*

    Specify type of residential unit.

    1. House
    2. Studio
    3. Apartment Complex
    4. Other
27. Number of Bedrooms*
    -- Select One --0123456
29. Number of Bathrooms*
31. Number of Total Rooms*
33. Please select all of the following amenities that are included in your rent payment*

    1. Heat
    2. Hot Water
    3. Electricity
    4. Air Conditioning
    5. Attic and/or Basement Storage
    6. Cable
    7. Washing Machine
    8. Dryer
    9. Refrigerator
    10. Stove
    11. Dishwasher

    1. Garbage Disposal
    2. Lawn Maintenance
    3. Snow Removal
    4. Tennis Court
    5. Pool
    6. Garage
    7. Off-Street Parking
    8. Security System/Guard
    9. Gym/Fitness Center
    10. Other
35. Is the unit furnished?*

    1. Yes
    2. No
37. If the unit is furnished, please indicate below the type of furnishings included.
39. Do you have a written agreement or lease with your landlord?*

    1. Yes
    2. No
41. If yes, please specify term.
    -- Select One --WeeklyMonthlyYearlyOther
43. If yes, when does your lease expire?
45. Have you signed a new lease agreement? *

    1. Yes
    2. No
47. Have you consulted with an Attorney about this complaint? *

    1. Yes
    2. No
49. If you have consulted with an Attorney about this complaint, please provide their name, organization, and contact information.
51. How long have you resided at this unit?*
53. How many people currently occupy this unit with you? *
55. Are you up-to-date with your rent payment?*

    1. Yes
    2. No
57. If you are not up-to-date with your rent payment please explain.
59. Please state the reason for filing this complaint*

    1. Rent Increase
    2. Rental Unit Conditions
    3. Other
61. What was your rent prior to filing this complaint?
63. What is the rental increase amount?
65. What is the effective date of the increase?
67. How much was your last rent increase (prior to this one)? When did this increase take effect?
69. Have you discussed the increase in rent with your landlord?

    1. Yes
    2. No
71. Was the rental increase discussion with your landlord a written complaint or an oral complaint? What was your landlord's response?
73. Do you believe your landlord has maintained the rental unit in accordance with the agreement/lease that was signed?

    1. Yes
    2. No
75. Are there conditions within the unit that you consider unhealthy or unsafe?

    1. Yes
    2. No
77. Explain why you believe the increase in rent is excessive (if this is the reason for your complaint); why your landlord’s response to your property maintenance, health and/or concerns is inadequate (if this is the reason for your complaint); or what other complaint you wish to make that is within the Fair Rent Commission’s jurisdiction*
79. Relevant Documents

    Please upload any documents relevant to your complaint.  This can include your current lease, previous lease, documentation of communication related to your complaint, or Health District/Building Department complaints or reports.

80. Relevant Documents #2

    Please upload any additional documents relevant to your complaint.  This can include your current lease, previous lease, documentation of communication related to your complaint, or Health District/Building Department complaints or reports.

82. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you may still be required to provide a traditional signature at a later date, and 4) you affirm under the penalties provided by the law that the information that you have provided is true to the best of your knowledge.

    1. I agree.
84. Electronic Signature
Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field