2. Signatures are required before any action will be taken. Please complete the form, print, sign and submit to our office at 710 Mill Bay Road, Room 205, Kodiak, Alaska 99615, Attn: Community Development Department.
4. ILLEGAL LITTER VIOLATION COMPLAINT FORM
6. Name:*
8. Residence Address:*
10. Mailing Address (if different from above):
12. Contact Telephone: *
14. 
    
16. Date of occurrence:*
17. Approx. time of occurence(AM/PM):*
19. Location of occurrence:*
21. 
    
23. I observed a vehicle dump material such as:*
25. Provide license plate number, make, model, color, type, size, etc. of vehicle:*
27. List any distinguishing marks (Missing parts, dents, company logos, etc.)*
29. 
    
31. If an individual (with or without a vehicle) has committed an illegal litter violation, please provide information we may use to contact this person:
33. SIGNATURE INSTRUCTIONS (Required)
35. Signature is required before any action will be taken. Information about you will not be released unless a case goes to trial. By signing this form you consent to testify in court should legal action be taken.
37. Signature:
38. Date:
40. 
    
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41. Print Only

* indicates a required field