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2. PLEASE NOTE:

   Under the Freedom of Information Law, this signed complaint will be produced upon written request.

4. Contact Information
6. First Name*
7. Last Name*
9. Address1*
10. Address2
12. City*
13. State*
14. Zip*
16. Phone Number*
17. Email Address*
19. Location of Problem*
21. Please indicate the nature of your problem by checking the appropriate box(es) below:
23. 1. Weeds
    2. Dogs barking
    3. Abandoned vehicles
    4. Chemical discharge
    5. Litter
    6. ADA Complaint

    1. Blocked drainage channel
    2. Damaged sidewalk
    3. Overhanging trees/shrubs
    4. Noise nuisance
    5. Hazardous parking

    1. Storm sewer leaking/blockage
    2. Water leaking on roadway
    3. Loose/protruding manhole cover
    4. Discrimination Complaint
    5. Fair Housing Complaint
25. Brief Description (or other problem not listed)
27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field