Citizen Concern Form

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Any personal information you provide is only used to contact you for clarification of the information you report and to provide follow-up on the action. If your complaint is regarding water, sewer, trash or maintenance issues, please, call the office at 304.799.4315 immediately and speak with staff. All other issues, please, continue to fill-in information so your concern can be acted upon.
Complainant's Name
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone Number
Cell Phone
LOCATION OF CONCERN
Include exact address:
Street Address City State / Province / Region ZIP / Postal Code
If no address is visible, please describe the area in detail, including street intersections and landmarks.
DESCRIPTION OF THE CONCERN
Details about the specific situation you are reporting:
Vehicles complaints description/license number
Renter reporting unsafe or unhealthy conditions, please provide contact information for the property owner:
Property Owner Name
Property Owner Phone Number
The Town of Marlinton will process every report received through this form. If another agency is responsible for the issues, it will be forwarded accordingly. To inquire to the status of your report, after three business days, please contact the Town at 304.799.4315.
Official Use Only
DO NOT FILL OUT BELOW THIS POINT
Received by: ____________________________________ Date ______

Property Owner Verified As _________________________________

Concern forwarded to:
Administration ___
Buildings ___
Police ___
Maintenance ___
Flood Plain Coordinator ___
Outside agency, if so who (give contact information for follow-up) _________________________________
Follow-up action taken: (Use blank sheet of paper for further reporting or documentation and attach to this report.)
Case closed: Yes ___ No ___

By whom?____________________________________ Initials _____

Date ______

White Copy – Office Yellow Copy – Department /Agency
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Official Use Only