UCC-10 CODE OFFICIAL COMPLAINT FORM

UCC CODE OFFICIAL COMPLAINT FORM

Type or print all requested information clearly. Note that all of the information on this form may be subject to public disclosure by way of a court order.

Complaint Filed By

Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Fax

Date

COMPLAINT FILED AGAINST:

Name of Code Official

Address

Street Address City State / Province / Region ZIP / Postal Code

Title

Certification #

Employer

Address

Street Address City State / Province / Region ZIP / Postal Code

Provide the following information regarding the building or structure that is the subject of the complaint you are filing:

Check which of the following applies:

Provide the following information regarding the building or structure that is the subject of the complaint you are filing:

1-or-2-family residence

Other building or structure

Building Name or Site (if other than a residence):

Address

Street Address County City State / Province / Region ZIP / Postal Code

Political Subdivision Name

Complaint Allegations:

State as specifically as possible the allegations you are making against the code official named above. Do not merely indicate “See attachments”, expecting that the Department will be able to determine the substance of your allegations by reviewing any attachments. However, you may attach information that will substantiate your allegations. If more space is needed, attach additional 8-½” x 11” pages.

Allegation #1

Allegation #2

Allegation #3

Allegation #4

Allegation #5

Allegation #6

Allegation #7

Allegation #8

Describe any actions you have taken to resolve this matter prior to contacting the Department of Labor & Industry. If more space is needed, please attach additional 8-½” x 11” pages.