Complaint Form
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1
2FOR LREC USE ONLY
LOUISIANA REAL ESTATE COMMISSION
Assigned
/
/
Post Office Box 14785
Inv:
Baton Rouge, LA 70898-4785
(225) 925-1923 or (800) 821-4529 (LA Only)
COMPLAINT FORM
Complete this form in its entirety. Be sure to attach copies of all documents that have any
bearing on your complaint, including, but not limited to, listing agreements, purchase
agreements, leases, canceled checks, and agency disclosure forms. Some complaints are
not within the legal jurisdiction of the LREC. Investigators are available to discuss your
particular circumstance prior to filing an official complaint.
COMPLAINANT: ____________________________________________________________
(First)
(MI)
(Last)
MAILING ADDRESS: ________________________________________________________
Street
_____________________________________________________________________
City, State, Zip
TELEPHONE NUMBER: (
) __________________
(
) __________________
Home
Office
I wish to file a complaint against the following licensee(s), registrant(s), and/or certificate
holder(s), for what I believe to be a violation of the Louisiana Real Estate License Law
and/or Commission Rules and Regulations. I understand that in making this complaint, I am
subjecting the licensee(s), registrant(s), and/or certificate holder(s) to the possible censure,
suspension or revocation of his/her license, registration, and/or certificate. I further declare
that this complaint is being made in good faith, and I will be available to testify in the event
that a hearing is held.
RESPONDENT INFORMATION: This is the licensee, registrant or certificate holder against
whom the complaint is filed. Provide as much detail as known.
NAME: ___________________________________________________________________
(First)
(MI)
(Last)
COMPANY NAME:
________________________________________________________
COMPANY ADDRESS: ________________________________________________________
Street
_____________________________________________________________________
City, State, Zip
COMPANY TELEPHONE NUMBER: (
) ___________________
ADDITIONAL RESPONDENT INFORMATION: This is for naming an additional licensee,
registrant or certificate holder against whom the complaint is filed. Provide as much detail
as known.
NAME: ___________________________________________________________________
(First)
(MI)
(Last)
COMPANY NAME: ___________________________________________________________
COMPANY ADDRESS: ________________________________________________________
Street
_____________________________________________________________________
City, State, Zip
COMPANY TELEPHONE NUMBER: (
) ___________________
INV 2 06/2011
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