Form Information:

*** When completing this form, you must provide valid contact information. Anonymous submissions will not be accepted or acted upon. ***

Valid submissions will be directed to the Delhi Township Public Works Department. If you prefer not to use this form, you may contact us at (513) 922-8609.

Description of Concern

Issue Location

Address Number

Street Name*

Nearest Cross Street

Issue Categories

(check at least one)

*

Pothole Curb Repair Street Sweeping Stormwater/Drainage Problem Road striping Street Lights Damaged sidewalk Traffic Signs

Overhanging trees/shrubs Storm sewer leaking/blockage Water leaking on roadway Loose/protruding manhole cover Dead Animal Removal Roadway Debris Road Construction Complaint Other

Your Contact Information

First & Last Name:*

Address:*

Email Address:*

Daytime Phone Number:

Photo / File Upload

(if applicable)

Photograph: (Must be GIF, JPG, JPEG, or PNG file)

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Photograph: (Must be GIF, JPG, JPEG, or PNG file)

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Photograph: (Must be GIF, JPG, JPEG, or PNG file)

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)