HiddenCountyDelawareHolmesKnoxMedinaPauldingPortageSummitTrumbullTuscarawasWashingtonVan WertUnionJeffersonLickingMahoningFultonPickawayErieProvider (Name of agency)* Property Address* Street number, street nameCity* Date of Request* MM slash DD slash YYYY Contact Name* Phone*Email* Description of request*Description of maintenance or repairs needed. If the issue is an appliance, please list the Brand/Make/Model Number.Did a person cause this damage?* Yes No Can person be specified?* Yes No Name of person who caused damage* Is this issue causing additional damage?* Yes No Unknown Upload photos if applicableAccepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 512 MB.* Required field 62233
