This form can be used to request information, express a compliant, report a problem/issue and express a thank you. This form is NOT for request information available through an FOIA request.

Date*
Name*
Address*
Telephone #*
E-Mail Address
Village Official
Title
Other Party Involved
Other Party Approached
Remarks*
Filing Party Signature*
Village Official Signature
Date Received
Action Taken
Repeat Email Address