Dhcr Form Ra 60H – Fill Out and Use This PDF

Filing Instructions: Complete an original and two copies of this complaint and include a copy of any attachments to each copy. File the original, two copies and any accompanying documents at the address indicated above by personal delivery or mail. Failure to follow this procedure or include all required information may result in the rejection of this application. See Part II for definitions of harassment.

Part 1 (Must be filled in completely in every case)

Mailing Address of Tenant:

Name:

Number/Street:

Apt. No.:

City, State, Zip:

Telephone Number: (

)

(

)

(Residence)

(Business)

Mailing Address of Owner:

Name:

Number/Street:

City, State, Zip:

Telephone Number: (

)

(

)

(Residence)

(Business)

Name and Mailing Address of Managing Agent (if different from above):

Name:

Number/Street:

City, State, Zip:

Telephone Number: (

)

Address of Building (if different from above):

Number/Street

City, State, Zip Code

(Complete this box in all cases)

Number of

(Insert an address where you can be reached if you leave your present address)

Rooms

Occupants

Apt. No. & Location (as "no. 3,

second floor front", etc.)

Are you a SRO (Single Room Occupancy) tenant?

Yes

No

Are you or were you an employee of the owner?

Yes

No

RA-60H (8/03)

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Complete if your unit is in a co-op or condo: (write name and address of each listed below)

Unit Owner/Proprietary Lessee:

To Whom do you pay Rent:

Managing Agent for Rental Units:

Managing Agent for Co-op/Condo Units:

President or Chairman of Co-op/Condo:

Part II - Definition of Harassment

It shall be unlawful for any owner or any person acting on his or her behalf, directly, or indirectly, to engage in any course of conduct (including, but not limited to, interruption or discontinuance of required services, or unwarranted or baseless court proceedings) which interferes with, or disturbs, or is intended to interfere with or disturb the privacy, comfort, peace, repose or quiet enjoyment of the tenant in his or her use or occupancy of the housing accommodations, or is intended to cause the tenant to vacate such housing accommodation or waive any right afforded under the Rent Regulatory Laws.

There must be a willful interruption in services or a continuing course of conduct, as distinguished from an isolated incident.

Persons using this form may be summoned to testify under oath in court or before this agency in connection with criminal or civil action initiated on the basis of the statements contained herein. Painting complaints, other service complaints, and complaints of violations such as overcharges, bonus payments, furniture tie-in sales, security deposits, lease renewals, etc., should not be filed on this form, but on other appropriate forms which may be obtained at your local Borough or District Rent Office.

Penalties for Proven Violations: Owners found guilty of harassment are subject to fines imposed by the Commissioner of not less than $1,000 nor more than $5,000 for each offense. The Division of Housing and Community Renewal (DHCR) will permit no future rent increases once there has been a finding of harassment, until such finding is lifted by DHCR order. In addition, DHCR may refer harassment violations to the District Attorney. Harassment of a rent regulated tenant which causes physical injury is a Class E Felony, punishable by imprisonment and fine.

Part III - General Information

				(mo.)
1. Date you took occupancy:			Current rent charged:		(wk.)
Date current owner of building became the owner:

2.	Do you have a current lease? Yes		No	If yes, state the term of current lease: From ____/____/____ To ____/____/____
3.	Is rent being paid? Yes	No	Amount paid $			, Amount demanded $

4. Give total number of apartments (units) in building:

Occupied:

Vacant:

If there are vacant apartments (units) in the building, indicate whether they are left open, locked, boarded up or being altered:

8. Is there a tenant's committee in your building? Yes	No	If yes, indicate name, address and telephone number of the
Chairman of the Committee:

9. My apartment is regulated under Rent Stabilization; ETPA; Rent Control; Hotel Stabilization (includes SRO tenants.)

10. Do you authorize DHCR to communicate with your attorney/representative concerning this complaint?		Yes	No
If yes, indicate name, address and telephone number:

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Part V - Further Statement of Tenant

(State in this space additional facts which may assist Office of Rent Administration in processing your complaint)

All statements and attachments must be in English.

RA-60H (8/03)

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Part V - Further Statement of Tenant (cont'd)

(State in this space additional facts which may assist Office of Rent Administration in processing your complaint)

All statements and attachments must be in English.

I have read the foregoing and I hereby affirm under the penalties provided by law that the contents thereof are true of my own knowledge.

Dated:

RA-60H (8/03)

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