Form is successfully submitted. Thank you!No RepairsFull name*Phone*Email, if you have itAddress*Name of your building What problem/s do you have? Click all that apply, & 'Next' at Bottom when doneFlooding Water damageLeaksMold BedbugsRoaches and other pestsMice Broken locks / Entry DoorBroken locks / Front Apartment DoorBroken locks / Back Apartment DoorNo running waterNo hot water No electricityNo Heat Broken fixtures / ToiletBroken fixtures / Cabinets Broken fixtures / DoorsBroken fixtures / WallsBroken fixtures / Ceiling Fans Broken fixtures / otherLights outBroken appliances / Stove or ovenBroken appliances / Refrigerator or FreezerBroken appliances / Other Where do you have the problem/s? Click all that Apply*Living RoomBathroom BedroomKitchenOther Take up to 4 photos of your issue Upload% Completed0 Have you asked management for a Work Order?If no, please ask management for a Work Order*YesNo If yes, please upload a photo of it here. Click next if they didn't give you one. Upload% Completed0 If management didn't give out Work OrdersEnter the date/s that you asked them for one About how many times did you tell the office about the issue?*1 time2 times3 timesMore than 3 timesWhat date/s did you tell the office about your issue?About how long ago did you first start telling them?*2-3 days2-3 weeks2-3 months3 months or moreAbout How long has this problem been going on?2-3 days2-3 weeks2-3 months3 months or more If someone was with you when you told them, enter their information belowFull NamePhoneEmail Is your health and safety at risk by living with this problem? If so, please share if comfortable. Are other people in your building experiencing this problem?*YesNoIf so how many do you know of?*None3-55-1010-20Over 20 Do you want to make a complaint to City of Chicago as well? YesNoIf yes, “Call 311, and ask the operator for a reference #. If no, just click Submit! We'll be in touch soon. Make sure you left contact info. Answer the question below if you can. Legal HUD or CHA rent is usually 1/3rd of income.How much is your rent?About how much is your monthly gross income?Are there any other resources you need? Submit