City of Bridgeport:
Anti-Blight Appeal Form
Department of Health & Social Services
An appeal may be filed within 10 days of receipt of the certified mailing of the fine notice, in accordance with Connecticut General Statutes § 7-152c.
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Property Owner Full Name:
*
First Name
Last Name
Email Address:
*
example@example.com
Phone Number:
*
Format: (000) 000-0000.
Property Address: Street Number and Street Name
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Address: City/State/Zip Code
*
City/State/Zip Code
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address: Street Number and Street Name
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address: City/State/Zip Code
*
City/State/ZIp Code
Street Address Line 2
City
State / Province
Postal / Zip Code
Energov Number: (Number can be found on the Violation Letter)
*
Please provide a detailed explanation of your appeal, including grounds and any relevant information:
*
999 Broad Street, Bridgeport, CT 06604 | bridgeportct.gov/health 203-576-7765 (P) | 203-576-7793 (F)
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