Nuisance Complaint Form

(Under authority of Section 3707.01 of the Ohio Revised Code)

Printing: Use "File - Print". You may have to set your left margin to 0" (using "File - Page Setup" if the left side of the form is cut off when printed.

Return by mail to:      Fairfield Department of Health      1587 Granville Pike      Lancaster, Ohio 43130

Or Fax to: (740) 653-8556

 

Township                                

 

Complainant                                                                              Phone                                     

 

Address                                                                                                                  

                                    Street                                                       City                                         State                        Zip

 

Offender                                                                                    Phone                                     

 

Address                                                                                                                  

                                    Street                                                       City                                         State                        Zip

 

Address and directions to nuisance:

 

 

 

 

 

 

Nature of complaint (use back if more space is needed):

        

 

 

 

 

 

 

                                      _________________________

Date                                         Signature (required)

                                                                                                                                           

---

 

For Office Use Only

 

Date Received                                                                                          Date to sanitarian                                                                  

 

Referral to other Agency (check)                                                            Agency                                                                                   

 

Contact                                                                                                    Date                                                                                       

 

FDH 08/06