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).

   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