Please fill in all information below:

        Your name: 
             
          Address: 
          
             City: 
             
            State:   Zip code: 
		
 Rent control?   Yes     No       Number of bedrooms          Rent amount   

   Day phone: 
       
  Other phone: 

   E-mail: 

Complaint against:

         Building owner: 
       
          Address: 
          
             City: 
             
            State:   Zip code: 
       
            Phone: 
         
          Manager: 
            
             Phone:  

Description of Complaint (Please be brief, 1,000 character limit):

What do you consider a fair and reasonable settlement?

Other agencies contacted: