2. Date
4. Property Address
5. Unit #
7. Tenant's Name
9. Tenant's Phone Number
10. How long have you resided at this address?
12. How long have you been aware of the problem(s)?
13. Have you informed the landlord, owner, or property manager (in writing) of this complaint?

    1. Yes
    2. No
15. Have you had any additional conversation with the manager or owner?

    1. Yes
    2. No
16. Whom did you speak with?
18. Are you behind on your rent?

    1. Yes
    2. No
19. Are you being evicted?

    1. Yes
    2. No
21. What is the name, address, and phone number of your property manager or owner?
23. Nature of Complaint:
25. After submitting this request, you will be contacted by a Property Maintenance Inspector within (3) three working days from the day the complaint was received. If you wish to cancel a scheduled appointment, contact the Division of Rental Inspections at (217) 892-6804 at least 24 hours prior to the time and date of the inspection. Please note that if you schedule an inspection and then cancel without proper notice you will be subject to payment of a $25 inspection fee.
27. Signature of Complainant / Tenant
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29. 1. Receive an email copy of this form.
30. Email address

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31. Submit Submit and Print

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