Name:

Check here if you would like to remain anonymous:

Address of property suspected of code violation(s):

City:    Zip Code:

Phone:     Email:

Building Use (select one):  Select One Single Family Dwelling Multi-Family Dwelling Apartment Commercial Owner Occupied Tennant Occupied Uncertain Other-List Below

Other:

Alleged Violation(s):  Select One Open & Vacant Structure Overgrowth (grass, weeds, Kudzu) Junk Vehicle Junk, debris, trash Vacant Lot Leaking Other-List below No Water (hot/cold) No Heat

Other:

Additional Comments: