1. Name

2. Address

Postcode:

3. Contact telephone numbers

4a. Fax number

4b. E-mail address

5. Address and registration number of property concerned

6. Are you referring the complaint on behalf of someone else?
If the answer is "no" please go to question 11
Yes
No

7. Name

8. Address

Postcode:

9. Explain why you are referring the complaint

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

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

12. Have you received a final written response to your complaint from Land Registry?
Yes
No

13. When did you receive the response from Land Registry?

14. Has your complaint been referred to any other organisation? If so please provide details
Yes
No

15. Please explain as clearly as possible how would you like Land Registry to put the matter right for you?

16. Please forward all relevant documents to the ICR. Please list below the documents you are sending (Please post all documents to the ICR office)

Please read the following information and then check the box to confirm that you want to refer your complaint to the ICR

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

• You will need to handle personal details about me, which could include sensitive information in order to deal with my complaint effectively.
• You will need to exchange information about my complaint with Land Registry (for example to find out important facts about my case).
• You handle complaints in a different way from the courts, not requiring people to attend hearings in person, but resolving disputes by correspondence.
• 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.