Official Complaint Form printable pdf download

COUNTY OF MARIN

TITLE 24 OR ADA DISABLED ACCESS

OFFICIAL

COMPLAINT FORM

Please Print or Type Information:

Date Filed: __/__/__

Time: ____

Complaint No.: _____

Type: ____________________

Received by: __________________________________________________________________

(Official Use Only)

( ) 1. Letter

( ) 4. Field

( ) 2. Phone

( ) 5. Referral

( ) 3. County

( ) 6. Other _________________________________________

Complaint: __________________________________Telephone: (

) ____________________

Address (Optional):

_____________________________________________________________________________

Location Of Alleged Violation: _____________________________________________________

_____________________________________________________________________________

Unit: _______ Block/Lot ______/______

Use/Occupancy: ________________________

Complaint Description: Cite ADA, ADAAG, UFAS, or Title 24 Sections Violated, if known.

_____________________________________________________________________________

(For Official Use Only)

Owner: _______________________________________________________________________

Owner’s Address: ______________________________________________________________

Date Inspected: __/__/__

By: ______ Notice Provided to Owner ___(Yes) ___(No)

Comments: ___________________________________________________________________

_____________________________________________________________________________

Date Referred: __/__/__ To: ______________________________________________________

Date Abated: __/__/__ By: ______________________________________________________

C: Word \ H Drive RM \ ADA Disabled Compaint Form

Official Complaint Form