Your Name: _______________________________________________

Your Address: _____________________________________________

Your Phone Number: ________________________________________

Your Signature: _____________________________________________

Please answer the following questions and give it to a member of the Board of Trustees of Ponderosa Community Club.

1. Name of property owner or persons who have broken the rules.
2. Location, date, and time of alleged violation.
3. Have you filed a previous complaint regarding this situation? If so, when?
4. Is your property or personal safety threatened by this alleged violation? YES/NO
5. Nature of the alleged violation or complaint (use the back of the page if needed)

Your complaint is considered confidential. However, in the event prosecution is deemed necessary to gain compliance of a violation, the Chelan County Prosecutor may subpoena you as a witness)
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OFFICE USE ONLY:
Date/Time received

Rcv’d via mail/in person

Rcv’d by