NOTICE OF RESIDENT CONCERN

If this concern is a life threatening or other emergency, please call 911 for immediate assistance.

I AM A: *

Resident of this community Neighboring resident or business owner of this community Former resident of this community I wish to remain anonymous

You have requested to report this notice anonymously. The DCA will investigate your claim to the fullest extent possible and will not follow up with you regarding a resolution.

YOUR NAME *

First Name Last Name

ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

COUNTY OF THIS UNIT/COMMUNITY *

PHONE NUMBER *

Area Code Phone Number

EMAIL

example@example.com

NAME OF THE APARTMENT COMMUNITY *

NAME OF THE PROPERTY MANAGEMENT COMPANY *

DO YOU RECEIVE A HOUSING CHOICE VOUCHER? *

Yes No I am not sure

IS YOUR CONCERN REGARDING: *

IS YOUR CONCERN REGARDING (please select all that apply): *

Health and Safety Rent Increase Crime Dispute with the Property Management Company Program violation (HOME or Tax Credit Program) Non-renewal or Lease Termination

WHAT SIZE IS YOUR UNIT *

1 BEDROOM 2 BEDROOM 3 BEDROOM 4 BEDROOM

ARE YOU REPORTING A FAIR HOUSING CLAIM TODAY? *

YES NO

We do not discriminate on the basis of race, color, religion, sex, ethnicity, handicap/disability, familial status, national origin, age, marital status, domestic partnership status, source of income, type of occupation, gender identity, or sexual orientation in the admission or access to, or treatment or employment in, our housing programs and activities. If you have a Fair Housing concern you can contact the Office of Housing and Urban Development (HUD) at www.HUD.gov.

DATE OF THE INCIDENT OR THE DATE THAT THE INCIDENT FIRST OCCURED *

Date

THE CONCERN YOU ARE REPORTING TODAY: *

PLEASE PROVIDE A BRIEF NARRATIVE OF YOUR CONCERN: *

HAS MANAGEMENT BEEN NOTIFIED OF THIS CONCERN *

YES NO

PLEASE STATE THE REASON YOU HAVE NOT NOTIFIED YOUR MANAGEMENT COMPANY OF YOUR CONCERN: *

DATE THAT YOU NOTIFIED THE MANAGEMENT COMPANY OR OWNER *

Date

HOW DID YOU NOTIFY THE MANAGEMENT COMPANY OR OWNER

PHONE EMAIL LETTER OR OTHER WRITTEN NOTICE IN PERSON

Please provide any response or action that the Management Co. or Owner has provided

NAME OF THE PROPERTY MANAGER *

First Name Last Name

EMAIL ADDRESS OF THE PROPERTY MANAGER

example@example.com

PHONE NUMBER OF THE PROPERTY MANAGEMENT COMPANY *

Area Code Phone Number

PLEASE PROVIDE A NAME AND CONTACT NUMBER FOR THE PERSON ASSISTING YOU *

DID SOMEONE ASSIST YOU IN FILLING OUT THIS FORM? *

YES NO

PLEASE UPLOAD ANY SUPPORTING DOCUMENTS REGARDING YOUR CONCERN HERE

Browse Files

BY SELECTING "AGREE" I AFFIRM THAT THE ALL STATEMENTS PROVIDED IN THIS FORM ARE TRUE AND HONEST TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT FALSIFYING THIS FORM MAY RESULT IN A PROGRAM VIOLATION ON MY BEHALF *

AGREE