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Derelict Structure Form

  1. Assumption Parish Police Jury
  2. To the Assumption Parish Police Jury:
    The undersigned of the Parish of Assumption does hereby file complaint that the below stated property owner is in violation of the Assumption Parish "Derelict Structure" ordinance (06-19).
  3. Enter the date
  4. Enter your first name
  5. Enter your last name
  6. Enter your address
  7. Enter your city
  8. Enter your zip code
  9. Enter your email address
  10. Enter your phone number
  11. Enter the name of property owner
  12. Enter address of property in violation
  13. Enter city of property in violation
  14. Enter zip code of property in violation
  15. You are required to enter pictures of the vehicle/property in violation
  16. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
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  18. This field is not part of the form submission.