Special Needs Removal Card

Do you know of anyone who should be removed from the special needs list?  If so, please complete this form and the proper authorities will be notified.
(* = required information)
 
Name:*
Address:*
City:*
Village:
Township:
State:*
Zip Code:*
Phone:* - -
Reason for removal:*
Condition Improved
Person Moved
Person Deceased
I am completing this request for another person

Please enter your own information if submitting request for another person:
Name:*
Address:*
City:*
Village:
Township:
State:*
Zip Code:*
Phone:* - -