VILLAGE OF WAVERLY

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VILLAGE OF WAVERLY

COMPLAINT FORM

Location ____________________________________ Date_________________

Nature of Complaint

| | |Insect or Rodent Harborage |

| | |Refuse and/or garbage on property |

| | |Unsafe Sidewalks |

| | |Weed and Tall Grass Accumulation |

| | |Unsafe Pothole |

| | |Snow and/ or Ice accumulation on Sidewalks |

| | |Unsafe Building |

| | |Dangerous Tree |

| | |Unlicensed Vehicle |

| | |Cemetery |

| | |Other _______________________________________________________ |

Comments:______________________________________________________________

________________________________________________________________________

Name of Complainant _____________________________________

Address _____________________________________

Phone # ______________________________________

For Village Use

Referred To: _____________________________ Date: __________________

By: _____________________________________

Action Taken____________________________________________________________

_______________________________________________________________________

________________________________________________________________________

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