RA-81 (3/14)
Application For A Rent Reduction
Based Upon Decreased Service(s) - Individual Apartment
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.
Part I - General Information
1. My apartment is: Rent Stabilized Rent Controlled Hotel Stabilized SRO (Single Room Occupancy)
a. A Co-op/Condo (Complete the following):
Unit Owner/Proprietary Lessee:
Name of Cooperative Corp./Condo Assn.:
Managing Agent:
b. My building is managed by a 7a Administrator:
2. I moved into my apartment on _____/_____/_____. 3. The total number of apartments in this building is:
(a) I have SCRIE or DRIE. Yes No
(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: ________________________________
Date
(Name of 7a Administrator)
1. Mailing Address of Tenant: 2. Mailing Address of Owner:
Name:
Apt. No.: Number/Street:
City,
State, Zip Code:
Name:
Number/Street:
City,
State, Zip Code:
Telephone No.: Bus. Telephone No.:
Res.
3. Subject Building (if different from tenant's mailing address):
Apartment NumberNumber and Street
State of New York
Division of Housing and Community Renewal
Office of Rent Administration
Web Site: www.hcr.ny.gov
City, State, Zip Code
Docket Number:
(SEE REVERSE SIDE)
RA-81 (3/14)
Date
4. The conditions noted in this application were brought to the attention of the owner or agent by letter on _____/_____/_____
The letter was (check one): sent by regular mail; sent by certified mail; personally delivered. A copy of the letter and
proof of mailing is attached to this application.
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.
Example: Kitchen
There is a water leak under the sink in the kitchen.
X
Date
Tenant's Signature
DHCR, Gertz Plaza
92-31 Union Hall St., 6th Floor
Jamaica, NY 11433
False statements may subject you to penalties provided by law.
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.
Mail or deliver this form to the DHCR office listed below.
