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2. Location of Sidewalk Trip Hazard*

   [Please note the address of home closest to the potential trip hazard location.]

4. Description of Sidewalk Problem *
8. Reporting Person - First Name*
9. Reporting Person - Last Name*
11. Reporting Person - Phone Number*
13. Reporting Person - Email Address*
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15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

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