Address of Property, Facility Name or Driving Directions: (required)

Township:
Choose One... Batavia Franklin Goshen Jackson Miami Monroe Ohio Pierce Stonelick Tate Union Washington Wayne Williamsburg

Type: (required)
Private Residence
Rental Property
Food Facility
FoodBorne Illness
Other

Details of Complaint: (required)

Have you discussed this problem with the manager/owner?

Choose One... Yes No

Manager's Name:

Manager's Phone Number:

Manager's Address:

Your E-mail Address:
(required)

Your Name:

Your Phone Number:

Your Address: