Complaint Type:
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Problem Location Name:


Problem Address (numeric only):


Problem Street Direction:


Problem Street Name:
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Problem Street Type:


Problem Unit Number:


Problem City:
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Problem Zip Code:


Permanent Parcel Number:


Census Tract:


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Ward Number:
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Problem Date/Time:


Complaint Description:
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Complainant First Name:
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Complainant Last Name:
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Complainant E-mail:


Complainant Phone Number:
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