Free 52654.FH11 - Indiana

MANUFACTURED HOME CONSUMER COMPLAINT
State Form 52654 (6-06)

INDIANA DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE AND BUILDING SAFETY BUILDING CODE ENFORCEMENT DIVISION 302 West Washington Street, Room W246 Indianapolis, IN 46204-2739

CONSUMER INFORMATION
Name of consumer Address of consumer (number and street) City Telephone number Work telephone number State ZIP code

Other telephone number

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DESCRIPTION OF MANUFACTURED HOME
Name of manufacturer Address of manufacturer (number and street) City HUD certification label number(s) State ZIP code

Home size: Single
Date of purchase (month, day, year)

X

Multi
Date of manufacture (month, day, year)

X
Date of installation (month, day, year)

DEALER AND INSTALLER INFORMATION
Name of dealer Address of dealer (number and street) City State ZIP code

Name of installer
Address of installer (number and street) City Name of contact State ZIP code

COMPLAINT Please list each problem separately by room and attach on a separate sheet of paper. Include the following information if available:



Local building permits and inspection records. Copies of correspondences with manufacture and/or dealer. Copies of any work orders.

Mail completed form and all paperwork to the Indiana Department of Homeland Security at the above address.
Signature of owner Date of signature (month, day, year)