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2. Date of Complaint
   Date of Complaint
3. First Name
4. Last Name
6. Phone Number
7. Email Address
9. Complainant Address / Unit #
11. Complaint
    Describe in detail the nature of the alleged violation(s) of Chapter 161 Housing Code of the Burlington Municipal Code as follows
13. Have you contacted the Owner/Operator regarding the complaint?

    1. Yes
    2. No
14. Did the Owner / Operator fail to address the issue(s)?

    1. Yes
    2. No
17. Owner / Operator Name
19. Owner / Operator Address
21. Owner / Operator Phone Number
25. Office Staff Use Only
27. Date Complaint Received
    Date Complaint Received
28. Inspection Date
    Inspection Date
29. Attached

    1. Photos
    2. Owner Notice
31. Inspector Findings / Requirements
33. Inspector
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field