COMPLAINT - HOUSING CODE ENFORCEMENT JD-HM-35 Rev. 3-12 C.G.S. § 47a-14h CONNECTICUT SUPERIOR COURT HOUSING SESSION www.jud.ct.gov ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Instructions 1. Fill out the form. Sign the original form and make 3 copies of it. 2. Give all copies to the clerk of the court with form JD-HM-19, "Notice of Suit - Housing Code Enforcement" and the entry fee, or a request for waiver of the fee. 3. A hearing will be scheduled not more than fourteen (14) days after you give the clerk the complaint, or the return of service (made by the clerk), whichever is later. If there is no return of service, the plaintiff will be responsible for service. Name of case Complaint 1. The plaintiff is a renter or tenant in the building at (Street address, apartment number or floor, town) 2. The defendant is the landlord of that building. oral 3. The renter or tenant and the landlord entered into an ("x" one) written lease for the term of one ("x" one) month week year month week year, and it is due on the 4. The rent for the apartment is $ per ("x" one) day of each month, week or year. (Check the box below if you paid rent to your landlord this month, week or year and fill in the amount you paid.) Rent of $ month week year, has been paid to my landlord. for the current ("x" one) 5. On (date) , the tenant made a complaint about the premises to (Name of municipal agency/Comm. of Consumer Protection) This was at least 21 days before filing this action. 6. The plaintiff (rentor or tenant) has not been served with a notice to quit for nonpayment of rent before this action was started, and has not been served with a notice to quit for any other reason before making the complaint to the municipal agency or to the Commissioner of Consumer Protection. 7. The landlord has not maintained the premises as to the landlord is required to do under section 47a-7 (Landlord's Responsibilities) of the Connecticut General Statutes. The violations are the following: This complaint continues on the attached paper and that paper is made a part of this complaint. The Rentor or Tenant Requests: 1. An order requiring the landlord to make repairs very soon and to do what he or she is required to do under local, state and federal law. 2. An order to have a person (receiver) to collect rents and to use the money to correct conditions in the property which violate local, state, or federal law. 3. An order stopping other proceedings that concern this property. 4. Money, which may include reimbursement of rent that was paid to the court under section 47a 14h (h) of the Connecticut General Statutes. 5. Anything else the court thinks is proper. I swear that the claims in this complaint are true. Signed (Plaintiff) Subscribed and sworn to before me on (Date) Type in name of person signing at left Title of person signing Signed (Assistant Clerk, Notary, Commissioner of Superior Court) Military Service Affidavit I swear that: the defendant(s) is(are) in the military or naval service of the United States. I am unable to determine whether or not the defendant(s) in this action is (are) in the military or naval service of the United States. no defendant in this action is in the military or naval service of the United States, and that, to my personal knowledge (state facts showing defendant is not in such service): Signature and Title X Subscribed and sworn to before me on (Date) Signed (Assistant Clerk, Notary, Commissioner of Superior Court) Distribution: ORIGINAL - Court File COPY 1 - Defendant COPY 2 - Housing code enforcement agency COPY 3 - Plaintiff American LegalNet, Inc. www.FormsWorkFlow.com