EXHIBIT A SMOKING VIOLATION COMPLAINT

Office of the City Attorney                              Office Use Only

44 West Washington Street                              Rec’d:          Resp.             

Shelbyville, Indiana 46176

Tel: [phone] Fax: [phone]

This form is to be used to report a violation of Chapter 99 of the Shelbyville City Code of Ordinances which regulates smoking in public places and places of employment. Completed forms should be filed with the Office of the City Attorney at the address listed above.

COMPLAINANT INFORMATION:

Name:                                                                                                                                   

Address:                                                                        

Telephone:                                                                                                               

E-mail address:                                                                                                                       

INFORMATION REGARDING ALLEGED OFFENSE:

Location:                                                                                                                               

Date of violation:                                          Time of violation:                                                 

Person(s) responsible for violation:                                                                                            

Description of violation:                                                                                                           

I hereby give the City permission to contact me regarding the investigation of the offense herein alleged.

I furthermore hereby affirm that all of the information provided herein is, to the best of my knowledge, correct and accurate.

Signed:                                                              Date:                                                               

(Ord. 06-2564, passed 4-17-06; Am. Ord. 18-2848, passed 11-26-18)