Assistance with Secondhand Smoke in an Apartment or Condo Request Form

Secondhand Smoke in an Apartment or Condo Assistance Request Form

An employee will review your request within three business days
Name of the Building or Complex
Building or Complex Address

Street Address

Street Address Line 2
CityState / ProvinceZIP Code
City
Cities in Salt Lake County only
ZIP Code
ZIP codes in Salt Lake County only
Salt Lake County Health Department provides assistance to people who live in Salt Lake County only. For addresses outside Salt Lake County, please contact the appropriate local or county health department.

All requests are confidential.
Your Name

First NameLast Name
Your Phone Number
So we can follow-up with you, if necessaryFormat: 000-000-0000.
Your Email
example@example.com
Should be Empty:

Secondhand Smoke in an Apartment or Condo Assistance Request Form