Resident Complaint Form

2. Address of Complaint*

3. Date*
   Date

5. Parcel Number

6. Section

7. Subdivision

9. Property Owner’s Names

11. Property Owner's Address

13. City

14. State

15. Zip Code

17. Complaint*

19. Image of complaint

    Please upload image of complaint.

21. Anonymous Complaints Are NOT Accepted

23. Complaint submitted by*

24. Your Daytime Phone Number*

25. Your Email Address

27. Complaint retraction:
    If you submitted a complaint and you would like to retract it, please email the details to kchaney@liberty-township.com.

    If you submitted a complaint and you would like to retract it, please email the details to kchaney@liberty-township.com.

29. Your Address*

31. City*

32. State*

33. Zip Code*

37. Action / Inspection

39. Date
    Date

40. By

42. Action / Inspection

44. Date
    Date

45. By

47. Notified

    1. Building Department
    2. Health Department
    3. Sheriff's Office
    4. Soil and Water

49. Building Department Date
    Building Department Date

50. Health Department Date
    Health Department Date

51. Sheriff's Office Date
    Sheriff's Office Date

52. Soil & Water
    Soil & Water

54. This form is subject to examination under the public records information act.

Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field