IDENTIFICATION OF DETERIORATING CONDITIONS
PROPERTY OWNER OR TENANT: YOU MAY USE THIS FORM TO HELP YOU IDENTIFY SUB-STANDARD CONDITIONS IN THE HOME THAT MAY NEED REPAIR OR CORRECTIONS.
SAVE A COPY OF THIS FORM.
FOR THE PERSON FILLING OUT THIS FORM:Are you the Owner?: Yes No
Are you the Tenant?: Yes No
PLEASE INDICATE, IF KNOWN:
Do youknow if there is a child(ren) under the age of six years or a pregnant woman residing at this address?
Yes No / FILIER CONTACT INFORMATION:
Name
Street Address Unit#
City State Zip Code
Telephone: Work Cell
Email Address
CHIPPING, PEELING, CRACKING, and CHALKING PAINT: Identify areas where these conditions are occurring.
This room,
has chipping, peeling, cracking or chalking paint on the:
Walls/ceiling
Window sills
Window wells
Window frames
Porch
Door/door frame / This room,
has chipping, peeling, cracking or chalking paint on the:
Walls/ceiling
Window sills
Window wells
Window frames
Porch
Door/door frame / This room,
has chipping, peeling, cracking or chalking paint on the:
Walls/ceiling
Window sills
Window wells
Window frames
Porch
Door/door frame / This room,
has chipping, peeling, cracking or chalking paint on the:
Walls/ceiling
Window sills
Window wells
Window frames
Porch
Door/door frame
Structural Defects: Identify areas where these conditions are occurring.
This area,has the following structural defects:
Leaking ceiling
Leaking Roof
Leaking plumbing
Other / This area,
has the following structural defects:
Leaking ceiling
Leaking Roof
Leaking plumbing
Other / This area,
has the following structural defects:
Leaking ceiling
Leaking Roof
Leaking plumbing
Other / This area,
has the following structural defects:
Leaking ceiling
Leaking Roof
Leaking plumbing
Other
EXTERIOR: There is chipping, peeling, cracking, chalking paint in the following area(s):
Front Porch/Side
Child’s Play Area
Garage
Visible paint chips on the ground
To initiate the complaint process, give a copy of this form to your Local Minimum Housing Code Official at the time of inspection. A list of each city and town’s Building Official is printed on the back of this form. If you need further guidance or have questions please contact the HRC, Office of Healthy Housing and Lead at 222-4892 or CLAP at 785-1310.