Ra 81 Form – Fill Out and Use This PDF

1. Mailing Address of Tenant:						2. Mailing Address of Owner:
Name:						Name:
Number/Street:					Apt. No.:	Number/Street:
City,						City,
State, Zip Code:						State, Zip Code:
Telephone No.: Bus. (				)		Telephone No.: (			)
		Res. (		)

3. Subject Building (if different from tenant's mailing address):

Number and Street

Apartment Number

City, State, Zip Code

Instructions To Tenant: Before filing this application, you should first notify the owner or agent in writing of all the service decreases in this application. You should attach a copy of your letter and proof of delivery to the owner or agent. If you do not send a letter to the owner or agent and attach a copy with proof of mailing, the owner/agent will be given additional time to respond to your complaint.

Use this form if you want to report a decrease in services in your individual apartment which you have not already reported to us. If you want to report a decrease in building-wide services, please use Form RA-84. To complain about a lack of heat or hot water, use Form HHW-1. Both forms are available at the Rent Office at Gertz Plaza or your District/Borough Rent Office.

Mail or deliver the original plus one copy of the signed form and one copy of all attachments, to the Rent Office listed on the reverse side of this form. Keep one copy for your records.

PartI-GeneralInformation

a.	A Co-op/Condo (Complete the following):
	UnitOwner/ProprietaryLessee:
	Name of Cooperative Corp./Condo Assn.:
	Managing Agent:
b.	My building is managed by a 7a Administrator:

(Name of 7a Administrator)

2. I moved into my apartment on _____/_____/_____.

3. The total number of apartments in this building is:

Date

(b) Section 8 Program:	None	U.S. Dept. of Housing & Urban Development	N.Y. C. Housing Authority
Housing Choice Voucher		N.Y. C. Dept. of Housing & Preservation Development

If applicable, enter Certificate/Voucher Number: ________________________________

RA-81 (3/14)	(SEE REVERSE SIDE)

4. The conditions noted in this application were brought to the attention of the owner or agent by letter on _____/_____/_____

Important: You must submit proof of mailing or delivery (e.g. certificate of mailing, certified mail receipt, or signed receipt from owner/agent acknowledging personal delivery).

Part II - Description Of Decreased Service(s): Check the box next to the area where the condition (equipment or decreased service) exists. Describe in detail: (a) the condition which exists, or (b) the equipment or service which is not being maintained, and (c) the exact location (in the room) of the equipment, decreased service or condition which exists.

Please be as specific as possible in order to ensure the timely processing of your application.

The owner has failed to provide or maintain services or equipment in my apartment and the following conditions exist:

Kitchen:

Bathroom:

Bedroom (Specify which bedroom if more than one):

Living Room:

Dining Room:

Hall Inside Apartment:

Other (Specify which room and the problem):

Part III - Tenant's Affirmation

I have read the information on this form, and I affirm the contents to be true to my own knowledge.

Date	Tenant's Signature

False statements may subject you to penalties provided by law.

Mail ordeliverthis form to the DHCR office listed below.

DHCR,GertzPlaza

92-31UnionHallSt.,6thFloor Jamaica,NY11433

RA-81 (3/14)