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Request / Complaint Notification Form
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1.
Contact Information
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2.
Request Information
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Contact Information
First Name
Last Name
Phone Number
Preferred Contact Method
-- Select One --
No Contact Needed
Phone
Email
Letter via mail
Street Address
Apt / Suite Number
City
State
Zip Code
Email Address
Continue
Request Information
Request Type Selection
Please check all that apply, and complete the additional information requested.
General Question
Alley Complaint
Bike Pickup
Dead Animal Removal
Junk / Debris / Etc
Park Maintenance
Recycling Issue
Residential Pool
Sidewalk Issue
Street Maintenance
Traffic Workorder
Tall Weeds
Tree Maintenance
Question Topic
-- Select One --
City Clerk's Office
City Manager
Fire, EMS & Paramedics
Parks & Recreation
Police Department
Public Library
Public Works (Streets)
Water Resource Recovery (Sewer)
Unknown / Other
Question
Please provide as much detail as possible with your question so that we can do our best to provide the answer.
Alley: Address
Please provide the street address of the specific alley location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Animal Type
-- Select One --
Cat
Deer
Dog
Raccoon
Skunk
Squirrel
Other
Address Animal is located near
Please provide the nearest address and/or the full street names of the nearest intersection. (Include N, S, E, W and St, Ave etc)
Abandoned Bike: Number of days
Please indicate the number of days the bike has been left at the provided location.
Location Address
Please provide the street address of the specific location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Junk/Debris/etc Location
-- Select One --
Alley
Back Yard
Driveway
Front Yard
Parking
Side Yard
Other (Please include in details below)
Junk/Debris Type
-- Select One --
Appliance
Auto Parts
Brush/Yard Waste
Construction Material
Furniture
Vehicle
Other (Provide details below)
Junk/Debris/etc: Address
Please provide the street address of the junk/debris/etc location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Which Park?
-- Select One --
Barker Park
Buxton Park
Dayton Park
DeNelsky Park
Dog Park
Downey Park
Easton Park
McCord Park
Memorial Park
Moats Park
Pickard Park
Sesquicentennial Park
South Park
Park Issue?
-- Select One --
Bathrooms
Overgrown / needs mowed
Shelter
Other
Select the appropriate issue and provide details below.
Recycling Issue
-- Select One --
Items left in bin
Recycling not picked up
Other (please explain)
Recycling: Address
Please provide the street address of the specific location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Residential Pool Issue
-- Select One --
No Fence
Unkept
Other
Residential Pool Address
Please provide the street address of the specific location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Sidewalk Issue
-- Select One --
Cracks
Deterioration
Obstruction (vehicle, vegetation, water, etc)
Snow/Ice Removal
Trip Hazard
Other
Sidewalk Address
Please provide the street address of the specific location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Street Maintenance Options
-- Select One --
Asphalt Repair
Berm Repair
Damaged Curb
Debris on Street or Right-of-Way
Graffiti or Paint on Road
Guardrail Maintenance
Pothole
Roadside Landscaping
Snow Removal
Streetsweeping
Street Maintenance: Address and/or Intersecting Streets
Please provide the nearest address and/or the full street names of the nearest intersection. (Include N, S, E, W and St, Ave etc)
Tall Weeds: Address
Please provide the street address of the specific location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Traffic Problem
-- Select One --
Hazardous Intersection
Parking
Signs
Speeding
Visibility
Other
Traffic Problem Address
Please provide the nearest address and/or the full street names of the nearest intersection. (Include N, S, E, W and St, Ave etc)
Tree Maintenance Type
-- Select One --
Close to Power Lines
Dead/Dying
Low Hanging Branch(es)
Overgrown
Other
Location of Tree: Address
Please provide the street address of the specific location. Include direction (N, S, E, W) and street type (St, Ave, etc)
Additional details/information of the Request/Complaint
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Indianola, IA 50125
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