INFORMATION & QUESTIONAIRE FORM

( PLEASE FILL UP, SIGN, PRINT, SCAN & SEND IT TO OUR EMAIL : region4a@dhsud.gov.ph
together with your supporting documents)
WANT TO UNDERGO CONCILIATON-MEDIATION
WITH DHSUD R4A FOR POSSIBLE AMICABLE
SETTLEMENT? (YES or NO)
WANT TO FILE FOR A REFUND ? (YES or NO)

NAME OF COMPLAINANT (Registered buyer)

REPRESENTATIVE , if any*
CONTACT NUMBER / VIBER NUMBER
EMAIL ADDRESS

PROJECT NAME
(Building number / name / phase, if any)
PROJECT LOCATION
(Brgy., Municipality, Province)
NAME OF DEVELOPER
MAILING ADDRESS / EMAIL ADDRESS
CONTACT PERSON / CONTACT NUMBER

CONCERNED UNIT (Block/Lot/Unit number)

TOTAL CONTRACT PRICE
TOTAL AMOUNT PAID
DATE OF RESERVATION (date indicated in O.R.)
NUMBER OF MONTHS PAID

CONCERN

REASON :
(use extra sheet if necessary)

AMOUNT REQUESTED TO REFUND

(full refund, state the amount, etc.)

REASON
(state your reasons, use additional sheet if
necessary)

HAVE YOU INFORMED THE DEVELOPER OF YOUR

REQUEST / CONCERN? Please attach proof.

HAVE THEY REPLIED?

STATE YOUR COMMENT ON THEIR REPLY

NOTE:
 Schedule of Conciliation-Conference shall only be given if the following conditions are met:

Page 1 of 2
  The developer have properly informed of the concern and the request / solution thereof.
Attach proof (i.e email & sms conversation, letters, etc.)
 Submitted a duly filled up Agreement to Mediate
 Submitted a duly filled up Information & Questionnaire Form
 Secure Special Power of Attorney for those using representatives
 Conciliation-Conference shall be done via Zoom Application.
 I am aware of REPUBLIC ACT NO. 6552, AN ACT TO PROVIDE PROTECTION TO BUYER OF
REAL ESTATE ON INSTALLMENT PAYMENTS (Maceda Law)

SIGNATURE OVER PRINT NAME / DATE

Page 2 of 2