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2. Voter Name
   This is not required
3. Date
   Date
5. Address
7. City
8. State
   NEW YORK
9. Zip Code
11. Phone Number
12. Email
14. My intent in filing this form is for:
16. Check one:

    1. Concern

    1. Complaint

    1. Comment

    1. Other
18. Please provide as much information as possible:
20. Would you like to hear back from us about this?
    -- Select One --YESNO
21. If yes, what is the best way?
    -- Select One --MailEmailPhone
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field