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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
Email
Date
MM slash DD slash YYYY
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.
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