Date of Report:	[..]	PLEASE CHECK ALL THAT APPLY
Time of Report:	[..]	☐	Commercial	☐	Owner/Landlord
Reported by:	[..]	☐	Residential	☐	Rent/Lease
Account Number:	[..]

LOCATION OF INCIDENT:	[..]

COMPLAINT

Complainant’s Name:	[..]
Complainant’s Phone Number:	[..]
Complainant’s Address:	[..]	[..]	[..]

Street/PO Box	City	State

Nature of complaint:

Signature
[..]
Printed Name
[..]
Date

FOR OFFICE USE ONLY

Report issued to:	[..]
Date issued:	[..]	Date completed:	[..]
Work performed by:	[..]	Assisted by:	[..]

Work performed: