Concerned Citizen Rental Complaints
Tenant/ Complainant Name
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Complainant Phone Number
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Phone
Tenant Email Address
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Desired Date of Inspection
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mm/dd/yyyy
Address Number
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Address Street Name
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Address Zip Code
Property Type
Landlord Name
Landlord Phone
Phone
Landlord Email
Landlord Address
Check all conditions that apply for property
No Heat
No Electricity
No Water
No Hot Water
Elevator Not Working
Suspected Rental Property
Sewage in Basement
Clogged Drainage System
Broken Plumbing Fixtures
Broken Electrical Switches and/or Wall Outlets
Broken or Extremely Deteriorated Porch(s)
Broken or Extremely Deteriorated Steps
Missing or Extremely Deteriorated Handrail/Guardrail
Leaking or Damaged Roof
Broken Window(s)
Damaged Interior Walls
Vermin Infestation (Rats, Roaches, etc.)
Overflowing Dumpster(s) (Refer to DPW)
Extremely Deteriorated Garage
Other: (Describe)
If you entered other above, please explain:
Any additional comments?
3rd Party Agency or Housing Counselor submitting on behalf of tenant
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