Pesticide Application Complaint

Your Contact Information

Required fields are marked by an asterisk (*).
Format example: (913) 555-1212

Pesticide Application Complaint

It is important to complete this form within 60 days of discovering damage. K.S.A. 2-2457a.

Required fields are marked by an asterisk (*).

Location of injury or damage(legal description or address)

What was injured or damaged?:














Please provide the following information, if known:

Do you know/suspect a particular pesticide application was responsible?:
If you selected OTHER for the application type, please enter a description here.
Format example: 12/12/2012
Information provided may be subject to disclosure under the Kansas Open Records Act K.S.A. 45-215 et seq.