HiddenCountyDelawareHolmesKnoxMedinaPauldingPortageSummitTrumbullTuscarawasWashingtonVan WertUnionJeffersonProvider (Name of agency)* Property Address* Street number, street name, city, zip codeDate of Request* MM slash DD slash YYYY Contact Name* Phone*Email Description of request*Description of maintenance or repairs needed (Please, only one item per request).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 Date work needs to be completed* MM slash DD slash YYYY Upload photos if applicableAccepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 200 MB.* Required field Δ
