2. Complaint and Investigation Request
4. 
6. Name of Person Making Complaint*
8. Address1*
10. Address2
12. City*
13. State*
14. Zip*
16. Work Phone
17. Home Phone*
19. Email Address*
21. Town Resident*
    -- Select One --YesNo
22. Reside within 300 feet of address at which the alleged violation is occuring?*
    -- Select One --YesNo
23. Aware of other complaints filed for this violation?*
    -- Select One --YesNo
24. If yes, aware of other complaints filed, how many?
    -- Select One --12345
26. Address of Complaint/Violation
28. Parcel of Complaint/Violation
30. Owner Name
31. Occupant Name
33. Nature of the Complaint/Reason for investigation*
35. Health or safety threat?*
    -- Select One --YesNo
36. Quality of life impact? *
    -- Select One --YesNo
37. If yes to either of the health and safety or quality of life, please describe:
38. Are the alleged violations constant or do they repeat frequently? *
    -- Select One --YesNo
40. I CERTIFY (OR DECLARE) THAT THE FOREGOING IS TRUE AND CORRECT.
42. Complainant *
43. Date*
47. FOR OFFICE USE ONLY
49. Intake Initials
50. Date Recieved
51. Case Number
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field