Who is completing this form:*

Client
Seller
Realtor

Complainant's Name:*

First Last

Address:

Street Address City ZIP Code

Contact Phone:*

Date of Inspection:*

Date of Pre-Closing Re-inspection:

Date of Closing:

Date Moved In:

Warranty Service Plan Purchased?:*

Yes
No

Warranty Service Plan Company:

Former Owner/Seller Name:

First Last

Do You Have Copy of Disclosure?:*

Yes
No

Upload Disclosure Documents:

Drop files here or

Max. file size: 64 MB.

Detailed Description of Incident/Condition:*

Was condition observable at time of inspection?:*

Yes
No

Date you first became aware of the condition:

Did you learn of this condition any time prior to closing?:*

Yes
No

How did you learn of this condition?:

Did Seller of property provide any type of Disclosure Form?:*

Yes
No

Was the condition identified on the Disclosure Form?:*

Yes
No

Did you conduct a final or pre-closing inspection?:

Yes
No

Was condition visible at this inspection?:*

Yes
No

Why final or pre-closing inspection was not conducted?*

If you did not notice the condition yourself, who first observed and apprised you of it?*

Was any action taken on this condition prior to closing?:*

Yes
No

What action was taken prior to closing?

Was any action taken on this condition after closing?:*

Yes
No

What action was taken after closing?:

Did other service providers perform any other inspections/services as part of the purchase process?:*

Yes
No

Explain services provided by additional service provider(s):

Did you negotiate with Sellers based on any findings of the Home inspection?:*

Yes
No

How much did you negotiate and for what issues/items?:

Please provide additional comments regarding your knowledge of the condition:

Provide contact information for any contractors, servicepersons or other individuals that have identified, inspected or done work related to the conditions/concerns reported above?

Contractor/Service Provider/Individual Name:

Contractor/Service Provider/Individual Address:

Contractor/Service Provider/Individual Phone:

Contractor/Service Provider/Individual Comments:

Did you obtain an estimate or proposal to correct condition?:*

Yes
No

Amount of Estimate/Proposal:

Upload Copies of Proposal(s)

Drop files here or

Max. file size: 64 MB.

Has any work been done?:

Yes
No

Explain work done:

Signature of Homeowner*

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