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Citizen Action Request

2. Name (or Organization)

4. Address

6. City

7. State

8. Zip Code

10. Telephone

11. Email

13. Your Concern

    1. Clogged Ditch/Culvert
    2. Clogged Open Ditch
    3. Clogged Storm Sewer
    4. Drug Activity
    5. Graffiti
    6. Illegal Dumping
    7. Junk Motor Vehicles
    8. Noise
    9. Parking Problem

    1. Pot Hole / Street Rut
    2. Private Sign Complaint
    3. Property Issue
    4. Raw Sewage Overflow
    5. Reconstruction Request
    6. Sanitary Sewer Leak
    7. Sign Damaged/Missing
    8. Speeding Vehicles

    1. Stray Animals
    2. Street Lighting Request
    3. Street Repaving Request
    4. Traffic Sign/Signal Need
    5. Trash/Dumpster Problem
    6. Unsecured Building
    7. Water Line Leak
    8. Other

    (One per form)

15. Additional Details

17. Attach Photos

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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

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