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2. Your Name*
4. Phone Number*
5. Email Address*
7. Address of Dilapidated Structure*

   Example: 723 S. Lewis Street

9. Please describe the extent of the violation, and the effect of the situation to you or to your neighborhood.*
11. If necessary, are you willing to testify about this occurrence/violantion?*

    1. Yes
    2. No
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12. 1. Receive an email copy of this form.
13. Email address

    This field is not part of the form submission.

14. Submit

* indicates a required field