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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. Does your property contain defects (i.e. problems with plumbing, heating, flooring, ceiling, stairs, lighting, ventilation, etc)?*

    1. Yes
    2. No
41. If yes, please explain:
43. Have you made a complaint/notified the Bloomfield Building Department?

    1. Yes
    2. No

    If yes, please attach copies of your correspondence with the Building Department to this complaint.

45. Are the conditions of the property/unit sanitary/clean?*

    1. Yes
    2. No
47. If no, please explain:
49. Have you reported these conditions to the West Hartford-Bloomfield Health District?

    1. Yes
    2. No

    If yes, please attach copies of your correspondence with the Health District to this complaint.

51. Do you have a written agreement or lease with your landlord?*

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

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

    1. Yes
    2. No
61. If you have consulted with an Attorney about this complaint, please provide their name, organization, and contact information.
63. How long have you resided at this unit?*
65. How many people currently occupy this unit, including yourself?*
67. Household Income (Optional)

    Please complete the following question for yourself and for any other income-accruing resident of your unit.  The income of the tenant and other occupants of the property is a factor that the Commission considers in deciding whether to reset the rent. The Commission understands that this information is personal and sensitive, and will handle this information with care and consideration.  

69. Income #1 Gross Amount
70. Source of Income

    Examples: Job, State Assistance, etc

71. Frequency of Paycheck
    -- Select One --WeeklyBi-WeeklyMonthly
73. Income #2 Gross Amount
74. Source of Income

    Examples: Job, State Assistance, etc

75. Frequency of Paycheck
    -- Select One --WeeklyBi-WeeklyMonthly
77. Income #3 Gross Amount
78. Source of Income

    Examples: Job, State Assistance, etc

79. Frequency of Paycheck
    -- Select One --WeeklyBi-WeeklyMonthly
81. Do you have a Section 8 voucher?*

    1. Yes
    2. No
83. Are you up-to-date with your rent payment?*

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

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

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

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

     1. Yes
     2. No
105. The Fair Rent Commission will consider the following factors when considering whether or not to reset the rent in question:
     1. Similar rents for the same or similar accommodations; 
     2. The sanitary conditions;
     3. The number of bathtubs, showers, kitchen and bathroom sinks;
     4. The amenities, including furniture, furnishings, appliances, services etc.;
     5. The size and number of bedrooms;
     6. Repairs necessary to make such accommodations reasonably livable;
     7. Taxes and overhead expenses, including debt service, thereof;
     8. Whether the conditions of the accommodations are in compliance with the health and safety ordinances of Bloomfield and the state of Connecticut;
     9. The income of the tenant and the availability of accommodations;
     10. The availability of utilities;
     11. Damages done to the premises by the tenant, caused by other than ordinary wear and tear;
     12. The amount and frequency of increases in rent and/or rental charges;
     13. Whether/the extent to which the income from an increase in rental charges has been or will be reinvested in improvements to the accommodations.
107. Explain below 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. Please remember, if relevant, to discuss the 13 factors listed above.*
109. 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.

110. 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.

111. Relevant Documents #3

     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.

112. Relevant Documents #4

     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.

114. 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.
116. Electronic Signature
Leave This Blank:


118. 1. Receive an email copy of this form.
119. Email address

     This field is not part of the form submission.

120. Submit

* indicates a required field