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Bed Bug Complaint Form
Complete and submit this form to the Department of Licenses and Inspections if your leased residence is infested with bed bugs and the landlord fails to meet obligations to remediate the infestation.
Tenant Name
*
First Name
Last Name
Tenant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tenant Email
*
example@example.com
Tenant Phone Number
*
Please enter a valid phone number.
Landlord Name
*
First Name
Last Name
Landlord Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Landlord Email
example@example.com
Landlord Phone Number
*
Please enter a valid phone number.
If you have it, please upload documentation establishing that a landlord/tenant relationship exists (i.e. An executed lease agreement; proof of rent payment). You may be required to provide this documentation if the person or entity that you identify as your landlord disputes that they are your landlord.
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Type of complaint:
*
Landlord failed to respond to the initial complaint. Note: At least 10 days must have lapsed from the initial complaint
Landlord failed to comply in part or whole with recommended remedial services.
Date of initial complaint
-
Month
-
Day
Year
Date
Please upload a copy of the notification and delivery of the initial complaint
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If you have it, please upload a copy of the investigation results by the landlord.
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If a copy of the investigation results is not available to you, include as much information below of the lapse in service.
Declaration
*
I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief.
Signature
*
Limpar
Submit
Should be Empty: