Citizen Report

Public Works Department
3900 Berdnick Street
Rolling Meadows, Illinois 60008
847-963-0500

Mr. Ms. Miss Mrs.
First Name:
Last Name:
Address:
Home Phone:
Work Phone:
Date:
Email:
Problem Location: (If different than above.)

Comments: (Please give a short description of the problem you are reporting.)

or..

The Problem concerns one or more of the items below. Check those that apply.

	Broken Sidewalk
	Broken Curb
	Pot Hole
	Street Cave-in
	Parkway Cave-in
	Water on Pavement
	Water in Yard/Park
	Missing/Bent Street Sign
	Street Light Out
	Traffic Light Out
	Tree or Limb
	Graffiti
	Parkway Damage
	Debris
	Obstruction
	Street Light Decoration
	Sewer Gas Smell
	Manhole Cover Missing
	Fire Hydrant
	Barricade Knocked Down
	Vandalism City Property
	Snow/Ice Build-up
	Leaking Water Meter
	Compliment or Suggestion
	Other