Derelict Vehicles and/or Junk Form

2. Assumption Parish Police Jury
4. To the Assumption Parish Police Jury:
   The undersigned of the Parish of Assumption does hereby file complaint that the below stated property owner is in violation of the Assumption Parish "Derelict Vehicles and Junk" ordinance (06-18).
6. Date*
   Date
   Enter the date
8. First Name*
   Enter your first name
9. Last Name*
   Enter your last name
11. Address
    Enter your address
13. City
    Enter your city
14. Zip Code
    Enter your zip code
16. Email Address*
    Enter your email address
17. Phone Number
    Enter your phone number
19. Property Owners Name*
    Enter the name of property owner
21. Address to Property in Violation of "Derelict Vehicles and Junk" Ordinance*
    Enter address of property in violation
23. City*
    Enter city of property in violation
24. Zip Code
    Enter zip code of property in violation
26. Vehicle/Property Pictures*
    You are required to enter pictures of the vehicle/property in violation
28. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
30. Electronic Signature*
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field