Landlord / Apartment Complaint Form

Are you currently renting from the Landlord in question?	Yes     No
Do you have a written contract with the landlord?	Yes     No
Have you contacted the Landlord / Manager about the problem?	Yes     No

	*Name:  (separate multiple names with comma)	Relationship:  I am/was the Renter No realtionship with Renter I am a relative of the Renter Friend of Renter
	* Rental Street Address:  (If applicable; include apartment #)	*City:	*State:  - - Select a State - - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	*Zip Code:
	*Current Mailing Address    Same as Rental Address	*City:	*State:  - - Select a State - - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	*Zip Code:

* Primary Phone:  (xxx)xxx-xxxx

Secondary Phone:  (xxx)xxx-xxxx

Email:  (Kept Private / no spam)

Fax:  (optional – not needed)

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# of People in Rental?: (numbers only)	# of Bedrooms: (numbers only)	# of Bathrooms: (numbers only)	Rental Amount [$]:	Deposit Amount [$]:

* Landlord / Manager Name: (Separate Multiple Names with Comma)  Business/ Apartment Complex Name (if Available / Applicable) *Business Mailing Address: (Typically Where Rents Are Mailed / Include Suite) *City:  *State:  - - Select a State - - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip Code:  Check this box if there is an additional contact such as: Owner, Property Management Company, Corporate Office, Collection Agency, etc. * Landlord / Manager Name: (separate multiple names with comma)  Business/ Apartment Complex Name (if available) *Business Mailing Address: (Typically where rents go/ include Suite)  *City:  *State:  - - Select a State - - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip Code:

*Primary Phone: (xxx)xxx-xxxx

Secondary Phone: (xxx)xxx-xxxx

Email: (Kept Private / no spam)

Fax Number: (optional – not needed)

	*Reason for Filing :  -- Select Reason -- Seeking Resolution Report Landlord Learn my rights Alert Other Renters	*Complaint Severity:  -- Select Severity -- 1 (minor) 2 3 (average) 4 5 (major)	* Title of Complaint: (e.g: Loud Neighbors,Breach of Agreement)
			0 /75 Maximum limit is 75 Characters
	*Problem Ongoing?: -- Select One -- Yes No Not Applicable	*Are You at Fault?: -- Select One-- Yes No Not Applicable	*Has Landlord Attempted to Resolve the Problem?: -- Select One -- Yes No Unwilling Unaware of problem Not Applicable

* What is Your Purposed Resolution? (Create up to 5 specific requests. i.e: 1. Refund $300 Deposit, 2. Reimburse for RPA® Fees, etc.) 1. Add another 2. Add another 3. Add another 4. Add another 5.
Additional Details Pertaining to This Complaint. (Provide details specific to this complaint. Avoid allegations, hostile tone or lists of other problems that aren’t applicable)
0 /2500    Maximum limit is 2500 Characters    ( Once the complaint is filed, other details, pictures, letters, etc can be added to your case.)
OPTIONAL Private Message to Mediation Agent (This section is ONLY if you need to relay some confidential information to the RPA Agent.)
0 /500	Maximum limit is 500 Characters