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Form L06 DEVELOPMENT SERVICES DEPARTMENT Builders’ Services Division Licensing 840 W 11TH ST. Panama City, Florida 32401 UNIFORM COMPLAINT FORM Your Name: Address: City: State: Zip: H o m e P h o n e : ( _ ) _ _ _ _ _ _ _ _ C e l l / O t h e r P h o n e : ( ) _ _ _ _ _ _ _ _ Your Occupation: Contact Name (other than yourself): Address: City: State: Zip: Home SUBJECT OF COMPLAINT Contractors Name: Address: City: State: Zip: Business Phone:( License # Occupation: Have you contacted subject concerning complaint? ( ) Yes ( ) No If “Yes”, what is the date(s) contacted: Contact was made through written communication ( ) Contact was made by phone ( ) Contact was made by email ( ) Phone number: Email If contact was made through written communication, please provide copies of written communication sent and received. If contact was by text messages, please provide screen shots of the text communication. If contact was by email, please provide copies of the email communication. Were there witnesses to your complaint? If yes, please provide the witness full name, address, and phone number or email address: ---PAGE BREAK--- Form L06 NOTE: A copy of this form will be sent to the SUBJECT of your complaint, pursuant to 455.255 of the Florida Statutes. Please give full detail of your complaint. Include facts, details, and dates. Attach copies of bills, documents, records, correspondence and contracts. It is your responsibility to provide factual documentation that will support your complaint. Florida Statues 837.06, False Official Statements: Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree. Signature (required to file complaint) Date