Date_________________

Please identify the problem.

Address of property____________________________________________

Please check all that apply.

__Yard Waste/Junk or Trash on Property

__Grass/Weeds over 8 inches high

__Vehicle(s) Abandoned on Property or on Sidewalk or Lawn or Persistent Speeding

Vehicle(s) Description____________________________________________

_____________________________________________________________

__ Dog or animal Complaint

__Trees or Shrubs Blocking Sidewalk

__Loud Music/Noise/Inappropriate Behavior

__Other

Please provide details/comments__________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

May we contact you regarding this complaint? All information is Confidential ____yes ____no

FORM MUST HAVE THE FOLLOWING INFORMATION:

Name______________________________________________Phone______________________

Place in the dropbox at town hall, email to: clerk@villageofpemberville.org or mail to: Fiscal Officer, PO Box 109 Pemberville, OH 43450