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2. Location of Problem
   Please provide exact address or street with block range or street with nearest cross street.
4. Vehicle Make
   Remember the more detail you provide, the better of a chance we will have to take action.
5. Vehicle Model
   Remember the more detail you provide, the better of a chance we will have to take action.
6. License Plate of Vehicle
   Remember the more detail you provide, the better of a chance we will have to take action.
7. Vehicle Color
   Remember the more detail you provide, the better of a chance we will have to take action.
9. A Brief Description of the Problem*
   Remember the more detail you provide, the better of a chance we will have to take action.
11. First Name
12. Last Name
14. Email Address
15. Phone Number
17. Picture of the Vehicle (Including License Plate)
    Remember the more detail you provide, the better of a chance we will have to take action.
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

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