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Housing Complaint Form
Complete All Applicable Fields
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Full Name
*
Email Address
*
Phone Number
*
other Have
Home Address
*
Preferred Contact Method
Choose One
Phone
Email
Mail
Property Address (if different from home address)
*
Type of Housing
Choose One
Apartment
House
Condominium
Mobile Home
Other
Landlord/Property Owner Name
*
Landlord/Property Owner Contact
*
Nature of Complaint
*
Unsafe or Unhealthy Living Conditions
Lack of Repairs or Maintenance Issues
Pest Infestation (Rodents, Bedbugs, Cockroaches, etc.)
Heating/Air Conditioning Not Functioning
Water or Plumbing Issues
Electrical Problems
Mold or Mildew
Lead Paint or Asbestos Concerns
Discrimination (Race, Gender, Disability, etc.)
Retaliation or Harassment from Landlord
Unlawful Eviction Threat
Security Deposit Dispute
Lease Agreement Violation
Other (please specify)
Nature of Complaint
Describe the issue in detail (including dates and previous attempts to resolve)
Have you reported this issue to the landlord?
Choose One
Yes
No
If yes, What was their response?
Additional Information
Are other tenants affected by this issue?
Choose One
Yes
No
Have you contacted other agencies (e.g., housing authority, legal aid)?
Choose One
Yes
No
If yes, Provide details
Upload Supporting Documents
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Photos, Emails, Lease, Repair Requests, etc.
Upload Supporting Documents
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Agreement & Submission
*
I certify that the information provided is true and accurate
Agreement & Submission
Signature
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