ADOH-OMH 301/302 (rev 2/2018)
PLEASE PRINT (USING INK ONLY) OR TYPE
DEPARTMENT OF HOUSING
1110 West Washington, Suite 280
Phoenix, AZ 85007
COMPLAINT FORM
COMPLAINANT'S NAME: __________________________________________________________ Daytime Phone: __________________________
E-MAIL: _________________________________________________________________________ Work Phone: ___________________________
Mailing Address: _______________________________________________________________________________________________________
CITY STATE ZIP
Unit Address: _____________________________________________________________________________________________________
CITY STATE ZIP
Name of mobile home park or subdivision: _________________________________________________________________________________
M
ANUFACTURER: ________________________________________________________________ Phone: ______________________________
A
ddress: ______________________________________________________________________________________________________________
DEALER: ________________________________________________________________________ Phone: ______________________________
A
ddress: ______________________________________________________________________________________________________________
S
alesperson: __________________________________________________________________________________________________________
I
NSTALLER: _____________________________________________________________________ Phone: ______________________________
A
ddress: ______________________________________________________________________________________________________________
THE UNIT IS SERIAL #:
__________________________________________________________________
NEW PURCHASE DATE: ___________________________________________________________
USED INSTALLATION DATE: ________________________________________________________
I have enclosed a copy of my cosmetic walk-through form dated ___________________
A cosmetic walk-through was not performed on my home.
A map to the home’s location.
A copy of purchase agreement/contract and any addendums/change orders.
Manufactured/Mobile Home Residential Modular/Factory Built Building
I
TEMIZE COMPLAINTS NUMERICALLY. IF ADDITIONAL SPACE IS NEEDED, USE 8 1/2" X 11" SIZED PAPER (one-sided).
1. ____________________________________________________________________________________________________________________
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I HEREBY GIVE MY PERMISSION TO SEND A COPY OF THIS COMPLAINT TO THE LICENSEE(S) INVOLVED, AND IF MY COMPLAINT IS
VER
IFIED BY THIS OFFICE, I AGREE TO ALLOW THE LICENSEE(S) TO MAKE APPROPRIATE CORRECTIONS.
COMPLAINANT'S SIGNATURE DATE
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signature
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