1. Name

2. Address

Postcode:

3. Daytime telephone number

4a. Fax nunmber

4b. E-mail address

5. Name and address of property concerned

Postcode:

6. Folio number/s

7. Are you the complainant
Yes
No

8. Name

9. Address

Postcode:

10. Explain why you are referring complaint

11. Are you referring the complaint with the agreement of the above person/organisation?
Yes
No

12. Please explain your complaint/s as clearly and precisely as possible.

13. The ICR expects complaints to have been made to Land Registers before they are referred to this office. Have you received a final written response to your complaint from the Land Registers?
Yes
No

14. If you are unable to provide a copy of the complaint response, please say when you received it

15. How would you like Land Registers to put the matter right for you? Please continue on a separate sheet of paper if necessary.

16. Please forward all relevant documents to the ICR and let us know if you would like them returned.
Please list below the documents you are sending and continue on a separate sheet of paper if necessary.
(Please post all documents to the ICR office)

17. Has your complaint been referred to the Northern Ireland Ombudsman?
Yes
No

18. Are you planning legal action?
Yes
No

19. I would like the Independent Complaints Reviewer to consider my complaint. I understand that:

• You will need to handle personal details about me in order to deal with my complaint effectively;
• You will need to exchange information about my complaint with Land Registers Northern Ireland (for example, to find out important facts about my case);
• You will not usually meet people in person but will make contact by telephone, letter, fax or e-mail;
• You may publish examples of where things can go wrong, based on real cases, but you will always respect my privacy and keep my personal information confidential.

I would like the Independent Complaints Reviewer to consider my complaint and understand the above terms and conditions.