This form is to be utilized when a citizen or governmental official is requesting that a County Department investigate a possible violation of a County law or other health and safety related problem.

This form is confidential in accordance with County policy. However, the form must be released if required by a court of law.

Type of Complaint*

Animal Building without a Permit COVID19 Violations in Restaurants Environmental Hazard Garbage/Junk Restaurant Other Concern

If Other Concern, please specify the nature of the complaint:

COMPLAINANT'S INFORMATION:

Complainant Name (person completing this form)

Telephone Number

Mailing Address

City

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code

Email Address

Do you wish to be contacted with the results of this investigation?*

Do NOT contact me Email

Today's Date:*

DESCRIPTION OF VIOLATION / PROBLEM

Street Address of Violation / Problem*

Town*

Assessor's Parcel Number (APN)

Property Owner's Name(s) - if known

Property Owner Mailing Address:

Town:

Zip Code

Nature of violation or problem (please be as specific as possible):*

Photographs or other documents in support of the complaint: