FACTUAL STATEMENT FOR CAUSE EVICTION
(M.G.L. ch. 121B, § 32, ¶ Unnumbered Paragraph 7)
Name(s) of Resident(s): (Name[s] of Resident[s])
Date(s) of incident(s): (Date[s] of incident[s])
Approximate location(s) of incident(s): (Approximate location[s] of incident[s])
Nature of the incident(s) alleged as lease or agreement violation(s): (Describe the incident[s] alleged as lease or agreement violation[s]. BE AS SPECIFIC AS POSSIBLE; do not just list the lease provisions. DO NOT USE ABBREVIATIONS FROM POLICE REPORTS. Please summarize police reports - do not attach them.)
Names of parties involved: (Names of parties involved)
Description of the actions or activities of the parties: (Description of the actions or activities of the parties)
Any prior similar incidents (additional bases for termination of tenancy or occupancy rights): (Any prior similar incidents)
Basis for proceeding without grievance pursuant to M.G.L. ch. 121B, § 32, ¶ unnumbered paragraph 7:
A. The BHA has reason to believe that the Resident or a member of the Resident’s household has engaged in the conduct indicated below:
OR
B. The BHA has reason to believe that a guest or guests of the Resident or of a household member of the Resident, where the Resident knew or should have know that there was a reasonable possibility that the guest(s) would engage in such conduct, has engaged in the conduct indicated below:
Check all that apply:
The Resident household member or guest(s):
I. On BHA property:
(1) Has unlawfully caused serious physical harm to another Resident or an employee of the BHA, or any other person lawfully on the premises of the BHA.
(2) Has threatened or seriously physically harmed another Resident or a BHA employee, or any person lawfully on the premises of the BHA.
(3) Has destroyed, vandalized, or stolen property of a Resident or the BHA or any person lawfully on the premises of the BHA which thereby creates or maintains a serious threat to the health or safety of a Resident or an employee of the BHA or any person lawfully on the premises of the BHA.
(4) Has engaged in other criminal conduct which seriously threatened or endangered the health or safety of another Resident, an employee of the BHA or any other person lawfully on the premises of the BHA.
OR
II. On or adjacent to BHA property:
(1) Has possessed, carried, or illegally kept a weapon in violation of section ten of chapter two hundred and sixty-nine or possessed or used an explosive or incendiary device or has violated any other provisions of section one hundred and one, or has violated any other provision of sections one hundred and one, one hundred and two, one hundred and two A, or one hundred and two B of chapter two hundred and sixty-six of the Massachusetts General Laws (illegal weapons and bombs).
(2) Has unlawfully possessed, sold, or possessed with intent to distribute a controlled substance as defined as Classes A, B, or C under section thirty-one of chapter ninety-four C of the Massachusetts General Laws (all illegal drugs except marijuana and marijuana-derivatives such as hashish).
CERTIFICATE OF SERVICE
I, ______, on the ______day of ______, 20______did serve upon ______this Agreement
______by delivering in-hand to the following adult:______
at:______
______by leaving at the following address and by mailing first-class mail to the same address (MUST DO BOTH):______
______
Signature: ______
Printed name: ______
Form 121B-04A: Factual Statement
Page 3 of 3
Revised 8/6/09