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Code Complaint Form

2. Date & Time
   Date & Time

   Date & Time

4. Address / Location of Complaint

6. Address2

8. City

9. State

   Jacksonville, AR residents only

10. Zip

12. Nature of Complaint

16. Please provide at least one of the following:
    This is personal information of the complainant.

    This is personal information of the complainant.

20. First Name

21. Last Name

25. Or

    Or

27. Address1

29. Address2

31. City

32. State

33. Zip

37. Or

    Or

39. Phone Number

43. Or

    Or

45. Email

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field