Health Department Complaint Form This complaint is being registered by: Date * 01/01/2022 date_range access_time Name * date_range access_time Address * date_range access_time City * date_range access_time State * Please select an option Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * XXXXX date_range access_time Phone XXX-XXX-XXXX date_range access_time I am willing to sign an affidavit regarding the conditions listed below: * Yes No I am willing to testify to the conditions listed below in a court of law: * Yes No navigate_nextContinue Your Session Is About To Expire Click continue to extend your session. Your Session Has Expired Close your browser or click OK to begin a new session.