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2. Applicant Information / Referral
4. Name
5. Email Address
7. Property Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Email Address
16. Eligibility (Check all that apply)

    1. Senior (Age 62 and older)
    2. Veteran
    3. Disabled
    4. Low Income (Financial Hardship)
    5. Other
18. If other, please describe:
20. Code Compliance Information
22. Code Case Number(s):
24. Violation Types:

    1. Overgrown Yard / Weeds
    2. Debris / Junk Removal
    3. Exterior Property Maintenance
    4. Fence / Accessory Structure
    5. Health and Safety Hazard
    6. Other
26. If other, please describe:
28. Safety Concerns

    Are there any safety concerns staff or volunteers should be aware of? 

    1. Animals
    2. Physical Hazards (debris, unstable structures, sharp objects)
    3. Medical Conditions
    4. Other
30. If other, please describe:
33. Additional Details:
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field