Name *

First Name

Last Name

Phone

(###)

###

####

Have you or any tenant you know experienced the following?

- Problems with the physical condition of your apartment (such as mold, bugs, broken stairs, etc)

- Negative health impacts from poor housing conditions

- An absentee / unresponsive landlord

- Unable to move because of the high move-in costs for moving into an rental (such as having to pay up front for first & last month, security deposit, non-refundable cleaning fees, etc)?

- Difficulties receiving your full security deposit back from your landlord

- Unaffordable rent (greater than 30% of your income)

- Lack of available housing / hard to find a place to live

- Unable to live in a neighborhood you wanted due to exclusive housing laws (all expensive housing types)

- Housing discrimination

- Feeling unstable due to concern about where you're going to live

Can we share your story with others? *

Are we able to use your responses on the BTU website or in other BTU organizing materials?

Yes - Responses and name

Yes - Responses ONLY, no name

No - Do not share my story