RENT SECURITY COMPLAINT FORM ATTORNEY GENERAL ANDREW M. CUOMO STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL BUREAU OF CONSUMER FRAUDS AND PROTECTION Consumer Hotline For Hearing Impaired (800) 771-7755 TDD (800) 788-9898 http://www.oag.state.ny.us 120 Broadway, 3rd Floor New York, NY 10271-0332 TEL: (212) 416-8345 FAX: (212) 416-8787 The Attorney General investigates complaints that a landlord has failed to place security deposits in trust accounts or to pay interest on rent security deposits. We also try to assist tenants who complain that a landlord failed to return the rent security when the tenant moved out. If, however, the landlord refuses to return your security deposit because your landlord says that you failed to pay rent or damaged the apartment, you must generally go to Small Claims Court to resolve the dispute. Before forwarding this complaint to our office, you must attempt to resolve the matter with your landlord. Please complete this form only if your attempt to resolve your complaint with the landlord has been unsuccessful. Each tenant should submit a separate complaint form. You may duplicate this form or obtain additional copies from our office. Be sure to attach a copy (NOT THE ORIGINAL) of your lease, receipt or other evidence that you paid a security deposit and any other pertinent letters or documents. PLEASE PRINT 1. YOUR NAME: ADDRESS (CURRENT) Street No. Apt. No. City TELEPHONE: State HOME Zip Code BUSINESS ADDRESS OF APARTMENT INVOLVED, IF DIFFERENT FROM CURRENT ADDRESS: Apt. No. Street No. City State Zip Code City State Zip Code State Zip Code 2. FORMER OR CURRENT LANDLORD INVOLVED IN THIS COMPLAINT: ADDRESS TEL.: Street No. 3. MANAGING AGENT'S NAME: ADDRESS: TEL.: Street No. City 4. APPROXIMATE NUMBER OF APARTMENTS IN BUILDING: 5. YOUR COMPLAINT CONCERNS: ( ( ( 6. ) ) ) Landlord failed to return rent security deposit. Landlord failed to place security deposits in trust account. Landlord failed to pay interest on security deposit. (a) AMOUNT OF SECURITY DEPOSIT AND DATE PAID: $ Date: (b) MOST RECENT MONTHLY RENT: $ (OVER) CNS 003NY (1/07) American LegalNet, Inc. www.FormsWorkflow.com 7. (a) DATE YOU MOVED INTO APARTMENT: (b) DATE YOU MOVED OUT OF APARTMENT (if applicable): (c) TERM OF FIRST LEASE: to 8. YOUR APARTMENT IS: ( ) Rent Controlled 9. Date you complained to the landlord: Person contacted: 10. ( By phone: ) Rent Stabilized Letter: Have there been any court proceedings regarding your rent security deposit? ( In person: ) Yes ( Other: ) No Has there been any other litigation concerning your apartment? If so, briefly summarize the issues. 11. If the building has changed landlords during your residence, please list them in order, starting with first. Use your recollection or your own records (such as rent checks or receipts) to prepare the list. Feel free to add a page if more space is needed. LANDLORD'S NAME, ADDRESS AND TELEPHONE NUMBER 12. PERIOD OF OWNERSHIP FROM -- TO MANAGING AGENT'S NAME, ADDRESS & TELEPHONE NUMBER Indicate the amount of interest, if any, you have received on your security deposit and the period involved. SPACE FOR ADDITIONAL INFORMATION, ANSWERS OR COMMENTS: IMPORTANT: In order to resolve your complaint, we may send a copy of this form to the parties you have named. In filing this complaint, I understand that the Attorney General is not my private attorney, but represents the public in enforcing laws designed to protect the public from misleading or unlawful business practices. I also understand that if I have any questions concerning my legal rights or responsibilities, I should contact a private attorney. I have no objection to the contents of this complaint being forwarded to the landlord the complaint is directed against. The above complaint is true and accurate to the best of my knowledge. I also understand that any false statements made in this complaint are punishable as a Class A Misdemeanor under Section 175.30 and/or Section 210.45 of the Penal Law. DATE: TENANT'S SIGNATURE: American LegalNet, Inc. www.FormsWorkflow.com