MORGAN COUNTY

HEALTH DEPARTMENT

180 S. Main St., Suite 252 Martinsville, IN 46151-1988 Phone 765-342-6621

Fax 765-342-1062

OFFICIAL COMPLAINT FORM DATE: _______________________

CODE NO.: ___________________

FROM:

Name: __________________________________ Phone No.: (__)________________

Address: ________________________________________________________________

COMPLAINT:

Describe Problem: ________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Precise Location of Problem: ________________________________________________

________________________________________________________________________

________________________________________________________________________

Person or persons RESPONSIBLE for the unsanitary condition:

Name: __________________________________ Phone No.: (___)________________

Address: ________________________________________________________________

• How long has this condition existed? ____________________

Please answer the following questions yes or no.

• Have you reported this unsanitary condition to the person responsible? ________
• Have you or any of your neighbors reported this unsanitary condition to the Health Dept. previously? ________
• Would you be willing to appear as a witness in the event legal action is instituted against the person or persons responsible for the unsanitary condition? ________
• May this agency refer your complaint to another agency if appropriate? ________

Signed: _____________________________ Dated: _______________________

NOTE: As our records are open to the public, we cannot guarantee confidentiality.