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2. Name*
3. Phone*
5. Email Address*
6. Date Seen*
   Date Seen
8. Vacant Property Location*
10. Additional Details of Vacant Property*
12. Photo of Vacant Property

    Please upload a photo if available.

Leave This Blank:


14. 1. Receive an email copy of this form.
15. Email address

    This field is not part of the form submission.

16. Submit

* indicates a required field