Forms • City of Madison • CivicEngage

If you have a concern, complaint, request or suggestion for the committee members that you would like to report, please fill out this form. Thank you for contacting us. Someone from the committee will be in touch within 48 hours

E-Mail*

Name (first and last)*

What district do you live in*

	District 1 - Maura Wroblewski
	District 2 - Connie Spears
	District 3 - Teddy Powell
	District 4 - Greg Shaw

	District 5 - Ranae Bartlett
	District 6 - Karen Denzine
	Distrct 7 - John Seifert
	I don't know my district.

Did you contact your District Council Member*

Yes

No

Date of Concern or Current Date (Format: MM/DD/YYYY)*

Time of Concern (Format: HH:MM)

AM/PM

Description of concern, complaint, request or suggestion*

Individuals involved in the incident/Issue (first and last name)

Location of concern, complaint, request or suggestion*

Actions you have taken to date*

Have you contacted your MPCAC District Representative

	Yes
	No

I don't know who my MPCAC District Representative is.

Recommended Solution for Issue Resolution

* indicates required fields.

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