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2. Issue (Choose One)*

   1. Pothole
   2. Roadkill
   3. Mailbox Damage
   4. Other
4. Description*
6. Location / Address
   Issue Location/Address
8. City / Township
   Issue City/Township
10. Contact Name
12. Contact Email Address*
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14. 1. Receive an email copy of this form.
15. Email address

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16. Submit

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