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2. Instructions
   This is an example of where your would list out in detail your instructions for filling out the form
4. The City of (Your City) FixiT Form will help us identify a problem in your area -- and fix it fast. Should a problem require urgent attention, please call us immediately. For a police emergency, dial 911. Otherwise, call (XXX) XXX-XXXX.
   Thank you for your assistance!
6. Contact Information
8. First Name*
9. Middle Initial
10. Last Name*
12. Address1*
14. City*
15. State*
17. Phone Number*
18. Email Address*
20. Please indicate the nature of your problem by checking the appropriate box(es) below:
22. 1. Pothole
    2. Damaged curb
    3. Traffic signals
    4. Weeds
    5. Dogs barking
    6. Abandoned vehicles
    7. Chemical discharge
    8. Water leaking

    1. Litter
    2. Road striping
    3. ADA Complaint
    4. Blocked drainage channel
    5. Street Lights
    6. Damaged sidewalk
    7. Traffic/Road signs
    8. Overhanging trees/shrubs

    1. Noise nuisance
    2. Hazardous parking
    3. Storm sewer leaking/blockage
    4. Water leaking on roadway
    5. Loose/protruding manhole cover
    6. Discrimination Complaint
    7. Fair Housing Complaint
    8. Other
24. Please Explain Other Issue *
25. Upload Additional Files
27. Brief Description (or other problem not listed)
29. Location of Problem
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field