Fillable Complaint Form (Allegany County, New York)

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Complaint Form (Allegany County, New York)

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The Complaint Form (Allegany County, New York) form is 1 page long and contains:

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585-268-9250 / 800-797-0581
Fax 585-268-9712
7 Court Street
Belmont, NY 14813
Allegany County Department of Health
Environmental Division
Complaint Form
Complainant: ____________________________________________________
Address: _______________________________________________________
_______________________________________________________
Telephone: ________________________(Home) _________________(Work)
Signature: ________________________________________________ _______
Complainant Date
Nature of Complaint: _____________________________________________
________________________________________________________________
________________________________________________________________
Location of Complaint – Town/Village ________________________________
Address: _______________________________________________________
_______________________________________________________
Directions to Location: ____________________________________________
Landowner/Responsible Party: _____________________________________
Address: _______________________________________________________
_______________________________________________________
Telephone: _____________________(Home) ____________________(Work)
If Residential Property, is Occupancy: Year Round:__________ Seasonal: ____________
If Rental Property – Name of Occupant(s): _____________________________________
Sanitarian: ____________________________________________________
Complaint Resolved – Yes: _____ No: _____ If “yes”, Date Resolved ____
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Complaint Form (Allegany County, New York)

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Completed 12 August 2021

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