Maintenance Work Order Form

Floyd County Housing Authority_logo
Phone: 606.285.3833 | Fax: 606.285.3835
402 John M. Stumbo Drive, Langley, KY 41645
FCHA-KY.org
Equal Housing Opportunity logo, Handicapped Accessible logo, and Website Accessible logo

Fields marked with * must be filled out or form not will submit.

Do not use this form for emergencies. Requests made with this form will not be processed until the next business day. If emergency maintenance is needed, outside of our office hours (after-hours) or on weekends, please visit our Maintenance page.

[{"type":"text","required":true,"label":"First Name","name":"first-name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Last Name","name":"last-name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Telephone Number","name":"Telephone-Number","className":"col-lg-4"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"Email","className":"col-md-6"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"email-confirmation","className":"col-md-6"},{"type":"text","required":true,"label":"Street Address","name":"Street-address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"City","name":"city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"State","name":"State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY","selected":true},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Zip Code","name":"zip-code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Description of Maintenance Request","name":"Description-of-Maintenance-Request","className":"d-block","subtype":"text"},{"type":"file","label":"If you have a photo of your Maintenance Problem, please upload it here. Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".<br>","name":"maintenance-problem-photo","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"Please do not submit any confidential, proprietary or sensitive personally identifiable information (e.g. Social Security Number; date of birth; driver's license number; or credit card, bank account or other financial information) via this form. Call our office at 606-285-3833 if the information you want to provide us is confidential or sensitive.","className":"d-block"}]