"Health Club Guaranty Fund Application - Club Closure" - Connecticut

Health Club Guaranty Fund Application - Club Closure is a legal document that was released by the Connecticut State Department of Consumer Protection - a government authority operating within Connecticut.

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Download "Health Club Guaranty Fund Application - Club Closure" - Connecticut

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STATE OF CONNECTICUT
For Office Use Only
DEPARTMENT OF CONSUMER PROTECTION
450 Columbus Blvd., Ste. 901
File No.:
Hartford CT 06103
Disposition:
dcp.investigations@ct.gov
HEALTH CLUB GUARANTY FUND APPLICATION - CLUB CLOSURE
CONSUMER'S INFORMATION
Your Name: ____________________________________________
Street Address: ____________________
City: _________________ State: ______
ZIP: _______
Work Phone: __________
E-mail address: _________________
Home Phone: _________________
HEALTH CLUB'S INFORMATION
Health Club:______________________________________
Street Address: ____________________
City: ________________
State: ______
ZIP: _______
Date of Closing: ________________
CONTRACT: A copy of your contract is the best form of proof.
Do you have a copy of your contract? ______
Is a copy of the contract attached? _______
If you do not have a copy of your contract, please indicate what proof you are providing:
____________________________________
Beginning Date of Last Contract: _______________
Ending Date of Last Contract:__________________
List total dollar amount of contract whether or not you paid it: $_____________
METHOD OF PAYMENT AND FREQUENCY
Method of Payment:
Credit Card ___
Debit Card ___
Check ______
Cash ______
Frequency of Payment:
Paid in Full ____
Monthly _____
Weekly _____
Other ______
Date of Last Payment: _________
If you pay by credit or debit card, did you dispute the charge and when?: _____ Was the charge removed? _____
DESCRIBE THE FEE PURPOSE:
AMOUNTS PAID
LATEST CONTRACT FEE BREAKDOWN
Membership fee
$___________________
Membership Fee
Maintenance fee
$___________________
Annual maintenance fee:
________________________________
$___________________
Other related items:
________________________________
$___________________
Other related items:
Note: Other related items are only for those items paid directly to the gym and may include additional payments
for classes, day care, additional passes. Exclude those amounts paid directly to others (ex: Trainers).
CERTIFICATION: I hereby certify that the foregoing statements are true and accurate to the best of my
knowledge. I have contacted the health club and requested a prorated refund of my health club membership fees.
To date I have not received any such payment from the health club. In the event that I also receive monies from
any other source, such as from bankruptcy court or from the health club owners for this claim, I agree to repay the
Health Club Guaranty Fund for any amount previously paid to me from the Fund for this claim. I hereby assign
all my rights, title and interest related to this claim to the Commissioner of Consumer Protection up to the amount
paid by the Fund.
Under penalty of law, I hereby swear to the truth of the foregoing.
Signature: ___________________________ Print Name: _____________________ Date: _______________
STATE OF CONNECTICUT
For Office Use Only
DEPARTMENT OF CONSUMER PROTECTION
450 Columbus Blvd., Ste. 901
File No.:
Hartford CT 06103
Disposition:
dcp.investigations@ct.gov
HEALTH CLUB GUARANTY FUND APPLICATION - CLUB CLOSURE
CONSUMER'S INFORMATION
Your Name: ____________________________________________
Street Address: ____________________
City: _________________ State: ______
ZIP: _______
Work Phone: __________
E-mail address: _________________
Home Phone: _________________
HEALTH CLUB'S INFORMATION
Health Club:______________________________________
Street Address: ____________________
City: ________________
State: ______
ZIP: _______
Date of Closing: ________________
CONTRACT: A copy of your contract is the best form of proof.
Do you have a copy of your contract? ______
Is a copy of the contract attached? _______
If you do not have a copy of your contract, please indicate what proof you are providing:
____________________________________
Beginning Date of Last Contract: _______________
Ending Date of Last Contract:__________________
List total dollar amount of contract whether or not you paid it: $_____________
METHOD OF PAYMENT AND FREQUENCY
Method of Payment:
Credit Card ___
Debit Card ___
Check ______
Cash ______
Frequency of Payment:
Paid in Full ____
Monthly _____
Weekly _____
Other ______
Date of Last Payment: _________
If you pay by credit or debit card, did you dispute the charge and when?: _____ Was the charge removed? _____
DESCRIBE THE FEE PURPOSE:
AMOUNTS PAID
LATEST CONTRACT FEE BREAKDOWN
Membership fee
$___________________
Membership Fee
Maintenance fee
$___________________
Annual maintenance fee:
________________________________
$___________________
Other related items:
________________________________
$___________________
Other related items:
Note: Other related items are only for those items paid directly to the gym and may include additional payments
for classes, day care, additional passes. Exclude those amounts paid directly to others (ex: Trainers).
CERTIFICATION: I hereby certify that the foregoing statements are true and accurate to the best of my
knowledge. I have contacted the health club and requested a prorated refund of my health club membership fees.
To date I have not received any such payment from the health club. In the event that I also receive monies from
any other source, such as from bankruptcy court or from the health club owners for this claim, I agree to repay the
Health Club Guaranty Fund for any amount previously paid to me from the Fund for this claim. I hereby assign
all my rights, title and interest related to this claim to the Commissioner of Consumer Protection up to the amount
paid by the Fund.
Under penalty of law, I hereby swear to the truth of the foregoing.
Signature: ___________________________ Print Name: _____________________ Date: _______________
THE HEALTH CLUB GUARANTY FUND
All licensed health clubs operating in Connecticut contribute part of their licensing fee to the Health Club
Guaranty Fund, administered by the Department Consumer Protection. The Guaranty Fund was established to
provide prorated restitution to former members upon the closing of their health club.
If a health club is no longer in operation at the location where the buyer entered into the contract, the buyer
having a claim against the health club may apply to the Department of Consumer Protection for payment.
Consumer claims arise from failure to provide services, failure to comply with contract obligations, failure to
remain open for the duration of contracts, and any other failure to comply with the provision of Chapter 420 of
the Connecticut General Statutes. Claims are filed when the health club fails to make payment on such claim.
No application for a payment from the Guaranty Fund shall be accepted by the Department of Consumer
Protection and the Commissioner more than six months after the date of the closing of the location of the health
club where the buyer entered into the contract.
Once six months have passed following a health club’s closing, the Department will hold a hearing. The
Commissioner may hear applications of all buyers submitting claims against a single health club in one
proceeding. The decision of the Commissioner shall be final with respect to the application.
After the hearing the Commissioner shall issue an order requiring payment from the Guaranty Fund of any sum
found to be payable upon such application. The order to distribute money from the Guaranty Fund will be on a
pro-rated basis to former club members who qualify for refunds.
Return the completed application including all attachments to:
VIA MAIL:
VIA E-MAIL:
dcp.investigations@ct.gov
Department of Consumer Protection
Investigations Division
450 Columbus Blvd., Ste. 901
Please be sure that your signature scans on the application and that all
attachments are included and readable.
Hartford, CT 06103
If you have any questions, please contact Investigations at (860) 713-6300 or email: dcp.investigations@ct.gov.
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