Tenant's Name*

Building Address*2216 Adams Place2428 Beaumont Avenue660 Crescent Avenue2246 Webster Avenue2247 Webster Avenue2249 Webster Avenue440 East 182nd Street1329 College Avenue1365 College Avenue1374 College Avenue1378 College Avenue1350 Ogden Avenue163 West 170th Street1791 Prospect Avenue756 East 175th Street2270 Washington Avenue480 East 183rd Street2183 Washington Avenue4470 Park Avenue2386 Bathgate Avenue469 East 184th Street517 East 187th Street1772 Weeks Avenue1776 Weeks Avenue1814 Weeks Avenue1360 Nelson Avenue1385 Nelson Avenue982 Prospect Avenue1051 College Avenue1055 College Avenue1106 Morris Avenue1114 Morris Avenue1330 Morris Avenue280 E. 166th Street2029 LaFontaine Avenue579 East 178th Street586 East 179th Street611 East 178th Street2045 Southern Blvd2319 Crotona Avenue4691 Park Avenue547 East 180th Street1993 Bathgate Avenue4424 Park Avenue380 East 173rd Street1068 Findlay Avenue1694 Clay Avenue1216 College Avenue1069 Walton Avenue315 East 170th Street369 East 169th Street1106 College Avenue1105 College Avenue1130 College Avenue1114 College Avenue2037 Webster Avenue758 East 168th Street764 East 168th Street1091 Prospect Avenue1421 Prospect Avenue1279 Rev. Polite Avenue25 Elliot Place1993 Morris Avenue565 East 178th Street2131 Clinton Avenue2089-91 Arthur Ave62-66 West Tremont

Apartment Number*

Contact Phone*

Email Address*

Number of Bedrooms

Number of Bathrooms

Missing Smoke DetectorMissing Carbon Monoxide Detector

Refrigerator:Defective orBroken

Stove:Defective orBroken

General:Peeling PaintCeiling Falling/ FellCracked/ Bulging WallsCeiling LeakingHole in the WallElectricity DefectiveMold on WallsElectricity Wiring ExposedWater DamageOutlets DefectiveLoose Floor TileSink CrackedBaseboards DefectiveFaucets Not WorkingWindow Frame DefectivePipes LeakingDoor BrokenLeaking FaucetRadiator/Raisers LeakingDrain Stoppage

Peeling PaintCracked / Bulging WallsHole in the WallMold on WallsWater DamageLoose Floor TileBaseboards DefectiveWindow Frame DefectiveDoor BrokenRadiator / Raisers LeakingCeiling Falling / FellCeiling LeakingElectricity DefectiveElectricity Wiring ExposedOutlets DefectivePipes Leaking

Toilet:Not WorkingLeaksSlow FlushingCrackedPipes LeakingBroken / Missing Toilet SeatBroken Toilet Paper RollerWon't Flush
Tub/Shower:Not WorkingInadequate Water SupplyCracked TileFaucet LeakingShower Head LeakingKnobs Broken / MissingClogged Drain
Sink:Not WorkingInadequate Water SupplyCracked TileFaucet LeakingKnobs Broken / MissingClogged Drain