Licensing Regulation & Enforcement
2725 Judge Fran Jamieson Way, Bldg. A-114
Viera, Florida 32940
Phone: (321) 633-2058, press 4, 6
contractorlicensing@BrevardFL.gov
COMPLAINT FORM
Please return this completed form and copies of any related documents such as
contracts, cancelled checks, etc. to the above address. Your complaint will be reviewed
and an investigator will contact you.
COMPLAINANT
Your Name:
Address:
(City) (State) (Zip Code)
Phone #: Email:
LOCATION OF ALLEGED COMPLAINT:
(City) (State) (Zip Code)
SUBJECT OF COMPLAINT
Contractor/Firm Name:
Address:
(City) (State) (Zip Code)
Phone #:
Did you sign a contract? YES NO Date:
An attempt will be made t
o assist you and the contractor in negotiating a resolution
whenever possible. If this is not possible, other actions may be taken depending on the
result of the investigation. Florida statutes 837.06, False Official Statements: Whoever
knowingly makes a false statement in writing with the intent to mislead a public servant
in the performance of his official duty shall be guilty of a misdemeanor of the second
degree.
SIGNATURE:
DATE:
Office Use Only:
Investigator Initials: _______ Case #: __________________________ Date: ___________________
Did you find this contractor/company, through the newspaper, yellow pages, and/or fliers?
YES NO OTHER
If NO or OTHER, how?
What was your initial reason for calling this person and/or company?
What was the name of the person(s) who came to your home for the original work and/or
estimate?
Did you ask him/them if they were licensed and insured? YES NO
If yes, did he/they show you something that led you to believe that he/they were
insured? YES NO
Did this person(s) tell you that he/they were licensed and insured? YES NO
If yes, what did he or they tell you?
If yes, what did he/they show you? (Business card, proposal, documents or other)
Were permits needed to do this work? YES NO UNSURE
Did he/they charge you for permits? YES NO UNSURE
Were you given a start and completion date? YES NO UNSURE
If yes, when?
Did he/they start as promised? YES NO
If no, why?
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Date work started:
Last date contractor was on site:
Did he/they complete the work as promised? YES NO
If no, why?
If the work was completed, were you satisfied with the work? YES NO
If no, why?
Did you make a complaint to the contractor/company? YES NO
If yes, who and what did you tell him/them?
Did you send him/them a letter stating your concerns? YES NO
What did he/they tell you in response to your complaint?
Did the contractor/company ever place a lien on your property? YES NO
If yes, what date was the lien filed?
What would you like the final resolution to be?
6.8.2020
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In your own words, please explain what happened from the beginning to the end. Please
print clearly.
Please use a separate sheet of paper if needed.
6.8.2020
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