Codes Complaints Form - Borough of Middletown, PA

Alleged Violation Information

Address of Alleged Violation:*

Street Address City State ZIP Code

Occupant Name (if known):*

Alleged Violation*

Complainant's Information:

Complainant's Name*

Complainant's Address:*

Street Address City State ZIP Code

Email*

Phone*

Submission Agreement*

I hereby affirm that the information contained in this Codes Complaint is true and correct to the best of my knowledge and is being provided with the intent that the representations in it may be relied upon by the Borough of Middletown in connection with potential enforcement actions or in the performance of other official governmental functions. This written Codes Complaint is intended to be made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

Complainant's Signature*

Please sign electronically.

All complaints must be signed and must contain the name of complainant. Anonymous complaints will not be investigated. Names of complainants will not be made public; however, please be aware should the complaint result in enforcement proceedings in District or Dauphin County court, the Borough cannot protect the complainant's anonymity.

Name

This field is for validation purposes and should be left unchanged.