§ 1. COMPLAINT FORM.

DATE OF ALLEGED VIOLATION:                                                                              

COMPLAINANT (person making complaint)

   NAME:                                                      

   ADDRESS:                                                   

   PHONE:                                                   

PERSON CHARGED (person against whom complaint is made)

   NAME:                                                      

   ADDRESS:                                                   

   PHONE:                                                   

IF COMPLAINT REFERS TO A SPECIFIC DWELLING:

   ADDRESS:                                                   

   OWNER:                                                   

   ADDRESS:                                                   

   PHONE:                                                   

DESCRIPTION OF ALLEGED VIOLATION:

(Please make a statement of the facts surrounding the alleged violation. Include names, dates and times if relevant. Try to include exact statements made by yourself and respondent.)

WITNESSES: (persons having knowledge of the facts)

   NAME:                                                   

   ADDRESS:                                                   

   PHONE:                                                   

   NAME:                                                   

   ADDRESS:                                                   

   PHONE:                                                   

   NAME:                                                   

   ADDRESS:                                                    

   PHONE:                                                   

                  Signature of Complainant

                  Date

                  Chairman or Vice-Chairman, Community Relations Commission

                  Date

*This complaint must be filed within 180 days of the “date of alleged violation.”

(`95 Code, Ch. 94, App. A)