Required fields are marked with asterisks (*)

Fire Safety Complaint Form

*IF THERE IS AN IMMEDIATE THREAT TO LIFE PLEASE CONTACT 911*

COMPLAINANT INFORMATION: (Please complete this section with your information)

Full Name:

Phone Number:

Address:

Email:

Are you the owner of this property?

Yes

SUBJECT OF COMPLAINT: (Please complete this section with the subject’s information, if known)

Owners Name:

Address:

Phone Number/Email Address:

Would you like your identity to remain confidential? (see note below)

Yes

Have you at any time previously submitted complaints about this property?

Yes

Do you wish to receive follow-up from the Officer assigned to this complaint?

Yes

Nature of Complaint:

Date(s) of Incident:

Please explain your concerns (who, what, when, where, how) & attach photos (if applicable)

Upload attachments

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

What, if any, actions have you taken to resolve the concern? (eg: spoken to landlord, removed hazard)

Note: Confidentiality will be maintained between the complainant and the alleged violator, except where necessary in a court of law. However, should this matter proceed to Court, you may be required to give evidence as a witness and your name and your filed complaint could become public information.

PLEASE SIGN HERE THAT YOU AGREE THAT THIS COMPLAINT DISCRIBED ABOVE IS TRUE AND ACCURATE TO THE BEST OF YOUR KNOWLEDGE.

Date:

Signature:

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Fire Safety Complaint Form

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