HAINES BOROUGH
CITIZEN CONCERN & SUGGESTION FORM
P.O. Box 1209 ♦ 103 Third Avenue S.
Haines, Alaska 99827
Ph: 907-766-6400 ♦ Fax: 907-766-2716
www.hainesalaska.gov
Today’s Date
:
Your Contact Information – It is the Haines Borough policy to disregard any anonymous comments received, unless
such comments are tips regarding health or safety issues. If you would like your health and safety tip to be anonymous,
please so indicate but we still need your contact information so we can obtain further information if needed.
Name: (first, middle initial, last) (Required)
Mailing Address: (address, city, state, zip code)(Required) Physical Address: (address, city, state, zip code)(Required)
Home Phone: (include area code) Work Phone: (include area code) Email:
Concern or Suggestion: Please include as much detail as possible. (Attach additional pages or use the backside of
this form, if necessary.)
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How do you suggest the borough address this? __________________________________________________
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This is a health and safety concern
I would like to remain anonymous (only for health and safety concerns)
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Signature
For Borough Use Only
Forwarded for Response to/date: Date Received by Borough Clerk:
Copy to Manager/date:
Results of Investigation: ____________________________________________________________________
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Action Taken
♦ Citizen Contacted regarding Results of Investigation:
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Contacted by Date
♦ Action:
Returned to Borough Clerk:
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Staff Member Date
Form Rev. 5/19
