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Parkersburg Housing Authority

Comment/Complaint Form

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Printable Version

Please provide the following contact information:

          Name: _____________________________

          Address: ____________________________

          Telephone: ________________

          Today's Date: _______________

  1. I wish to file a formal complaint against: ____________________

  2. Reason: _______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

  3. Please complete the following questions:

           Date of Incident: __________        Time of Incident: _________

            Witnesses: Y    N    Name:_____________________


            Police Called: Y    N     Officer's Name: ____________________

I have completed the above information to the best of my knowledge or belief. I understand that by placing a false complaint I am committing fraud and it is punishable by law. I understand that by placing a written complaint, I may need to testify to the facts as I know them in Magistrate's Court any/or any other legal proceedings.

_____________________________    _____________

Signature                                                Date


Copyright 1999 Parkersburg Housing Authority. All rights reserved.
Revised: 01/05/15


Copyright 2002 Parkersburg Housing Authority
Last modified: 10/06/15