1213 Thurston Ct NW VanderMeyden CAOFFICIAL USE ONLY RECEIVED
Oate Received JUG ] 7 1pO�
BY
CITY OF YELM
PO Box 479
Yelm WA 98597 ao
(360) 458 -3244 �tSh od >'o c�
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CITIZEN ACTION REQUEST
NOTE: Information provided on this request form is subject to public disclosure,
and is available to individuals upon request. If you wish to remain anonymous,
the City of Yelm reserves the right to not folIow-up on the request.
NAME:
PHONE: /�
Home liug-ness
ADDRESS: 12 )
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MAILING ADDRESS (if different than above):
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For City ofYelm Official Use Only:
Routed to: On:
Response /Information Given:
Suggested Action to be Taken:
Complaint and suggested action to Dept. Head
Action assigned to:
Action to be initiated by / /
Action taken if other than above:
Satisfactorily resolved /Completed on: / /
By: