Citizen Complaint Program

Please submit your form to the Village at P.O. Box 54

Name of Citizen:               _________________________________________________ 

Address:                           _________________________________________________

Date of Complaint:            _________________________________________________

Nature of Complaint:         _________________________________________________

                                          _________________________________________________

                                          _________________________________________________

 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

For Office Use Only:

Date complaint was resolved:            _______________________________

Action taken to resolve complaint:    

_____________________________________________________________________________

 ____________________________________________________________________________

Signature:  ______________________________________________