HUD-311-DR Federal Manufactured Housing Dispute Resolution - Inform

Federal Manufactured Housing Dispute Resolution Informational Form

U. S. Department of Housing and Urban Development Office of Housing Federal Housing Commissioner

OMB Approval No. 2502-XXXX (exp.(????))

Public reporting burden for this collection of information is estimated to average 58 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information is required to obtain benefits. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. 42 U.S.C. § 5422(g) (section 623(g) of the National Manufactured Housing Construction and Safety Standards Act of 1974) authorizes HUD to implement a dispute resolution program in each State that does not have a program meeting the requirements of42 U.S.C. § 5422(c)(12).This Dispute Resolution Certification Form will be used for states to self-certify the adequacy of the state’s dispute resolution program and for HUD to evaluate that self-certification. Your answers to the following questions are necessary for a proper evaluation of your dispute. The respondents are homeowners, installers, retailers, and manufacturers of manufactured housing. HUD does not pledge assurance of confidentiality to respondents. HUD generally discloses this data only in response to a Freedom of Information request.

Initial Information

Name of person submitting request requesting for assistance in resolving dispute:(e.g. Name: )

Role in the dispute: (check one)

Homeowner ___

Manufacturer ___

Retailer ___

Installer ___

Other parties involved in this dispute:

Homeowner ___

Manufacturer ___

Retailer ___

Installer ___

Information on the home

Street address of home:

City:

State:

Zip:

Daytime phone:

Evening or weekend phone:

E-mail address:

Name of manufactured home park, if applicable:

Single-Widewide:

Double-wide:

Multi--wide:

Serial Number number of Homehome:

Model Number number of Homehome:

HUD Label label Numbernumber:

Date Home home Was was Purchasedpurchased:

Date Home home Was was Delivereddelivered to the installation site:

Date Home home Was was iInstalled:

Additional information on person requesting the dispute resolution

Name:

Street Addressaddress:

City:

State:

Zip:

Daytime phone:

Evening or weekend phone:

E-mail address:

Manufacturer of Home

(Corporate Name name if Knownknown)

Company Name name of Manufacturermanufacturer:

Name of manufacturing plant in which home was built:

Name of contact person at plant if known:

Street Addressaddress:

City:

State:

Zip:

Telephone:

E-mail address:

Retailer of Home

Name of Retailer:

Name of contact person or salesperson at retailer:

Street Addressaddress:

City:

State:

Zip:

Telephone:

E-mail address:

InstallerInstaller of Home

Name of Company company that installed the home:

Name of person that installed the home:

Name of contact person for the installation company:

Street Address address of installer’s company:

City:

State:

Zip:

Telephone:

E-mail address:

List of ProblemsDescription of Dispute (use additional sheets if necessary)

Description of the dispute:

Have you previouslyfiled a written written complaint withto the federal Office of Manufactured Housing Programs? regarding this or other issues involving this home?If yes, date of complaint.

Have you contacted the [manufacturer, retailer or installer] regarding your complaint?

If yes:

Person/firm contacted

Date(s) Contacted

In writing or by phone?

Person/firm contacted

Date(s) Contacted

In writing or by phone?

Person/firm contacted

Date(s) Contacted

In writing or by phone?

Person/firm contacted

Date(s) Contacted

In writing or by phone?

Attach copies of all written correspondence to or from the manufacturer, retailer, installerinstaller, or homeowner. Also, attach copies of any other documentation to support your dispute. These documents will not be returned.

Printed Name of person submitting complaint:

Signature:

Date:

Description of Dispute (continued)

4 of 4 form HUD-311-DR (8/24/2005)