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2. Reporting Party
   Name and contact information for person reporting complaint
4. First Name
5. Last Name
7. Phone Number
8. Fax Number
10. Email Address
14. Complaint Information
    Include address and description of complaint.
16. Address
18. City
19. State
20. Zip Code
22. Description of Comlaint
24. Pictures
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field