Reporting form for complaints regarding annoyance

							Woonbedrijf


Reporting form for complaints regarding annoyance                                            page 1/2

You may use this form to report cases of annoyance to Woonbedrijf.
Woonbedrijf is entitled to use the information contained in this form to build up a file for use in
possible future legal proceedings.

1. Personal details of the party reporting the annoyance

Name:                                                                                 M/F

Address:
Postal code and city:
Home phone number:
Work phone number:
E-mail:

2. Personal det ails of the party causing the annoyance

Name:
Address:
Postcode and city:

3. Description of the annoyance (please include date and time)




4. Actions undertaken
• Did you address the person(s) causing the annoyance? r No           r Yes,         times
• If so, what was the outcome?




                                                                                         Send this form in an
                                                                                         unstamped envelope to:
                                                                                         Woonbedrijf
                                                                                         Antwoordnummer 10191
                                                                                         5600 VB Eindhoven
5. Did you call in the assistance of any third parties to help end the annoyance?     page 2/2
If so, who did you call in (such as the police, municipal district office, Novadic,
GgzE, neighbours)? If so, which steps were taken and did this achieve any results?




6. Did you report the incident to the police? r No r Yes (please include copy of
your statement to the police)

The undersigned hereby declares to have filled out this form fully and truthfully
and consents to Woonbedrijf using the information on this form in building up
a file for use in any future legal proceedings.
Forms without name, address and signature will not be dealt with.


Name:
Address:
Postal code and city:


Date:



Signature: