Austell, GA: Written Formal Complaint Form

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Complaintant's Information
Name:

First NameLast Name
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address:
Violation Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Complaint/Violation
Is this a safety or hazardous situation?
Signature
Complaint: Please describe in detail the nature of the problem and your complaint.
Please verify that you are human
Should be Empty:

Complaintant's Information