2. TO: Quality of Life Task Force

4. First Name*
5. Last Name*
7. Property Address*

   Please provide the street address of the property where the issue is occurring (not your personal address). 

8. Hamlet*
   -- Select One --CopiagueDeer ParkEast FarmingdaleNorth AmityvilleNorth Babylon North LindenhurstWest BabylonWheatley HeightsWyandanchBarrier Island
9. Type of Property*
   -- Select One --Residential CommercialUnsure
11. Nature of Compliant *

    Such as: illegal rental, commercial vehicles, bamboo etc.  

13. Description of Issue*

    If possible, please provide specifics such as names, plate numbers etc.

15. How long has this been going on? *
16. Time of day or day of week the issue occurs: *
18. Please answer the following questions to help us get a better understanding of the situation and determine if the Town or law enforcement have a record of issues at this location:
20. Has the complainant tried to resolve this issue directly with the other party? *
    -- Select One --Yes No
21. Has the complainant reported this issue to the Suffolk County Police Department? *
    -- Select One --Yes No
22. Has the complainant reported this issue to the Town of Babylon before? *
    -- Select One --YesNo
24. If this complaint involves a conflict with a neighbor or other known person, would you be agreeable to a third party mediation?*
    -- Select One --YesNoN/A
26. Would you like the Town to contact you for more information / to follow up? *
    -- Select One --Yes No

    If yes, please provide the best email and phone number to reach you at. 

27. Reply Email Address
28. Phone Number
30. Attachment One
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field