{[ADDR]}
{[CITY]}, {[STATE]} {[ZIP]}
{[APHONE]}
{[AWEBSITE]}

{[CNAME]} endeavors to deliver all public services in a professional manner and to respond promptly to all citizen inquiries and concerns.

{[CNAME]} will hold your information in confidence and will ONLY be used by an employee from {[CNAME]} to contact you in the event that more information about your concern is required.
Note, however, that all Report-A-Concern submissions are subject to public record requests.

In case you want to receive further information regarding your concern after submitting this application, you must fill your contact information below.

If you have any pictures or documents that would assist us in the handling of this concern, please attach them below.

• Do not take any pictures unless it is absolutely safe to do so.
• Please note that {[CNAME]} does not condone the entering of personal/private premises without authorization.
• {[CNAME]} will not accept responsibility or liability for any loss or damage to personal/private property, or any physical injury as a result.

REPORT A CONCERN IS NOT AN EMERGENCY REPORTING SYSTEM.
If your issue or concern involves an immediate risk to life or personal safety, Call 9-1-1 immediately.
All requests will be reviewed and addressed in accordance with {[CNAME]} policies and within the limits of available resources.

{[PNAME]}