2. Your Information
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. College Student?*

    1. Yes
    2. No
16. Relationship to Property*
    Owner, Neighbor, Concerned Citizen, Etc.
20. Complaint or Code Violation
22. Type of Violation*

    1. Fire Safety
    2. Garbage
    3. High Grass
    4. Housing Condition
    5. Junk Vehicle

    1. No Heat
    2. No Electricity
    3. Open Burning
    4. Over Occupancy
    5. Parking

    1. Sidewalk Not Shoveled
    2. Water-Related
    3. Vermin Infestation
    4. Other
24. Description of Violation*
26. Street Address*
27. Apartment Number
29. Rental Housing*

    1. Yes
    2. No
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

* indicates a required field