Voice Your Concerns

125 Beltline Road, Gaffney, SC 29341
PO Box 1477, Gaffney, SC 29342
Office Hours: Monday - Thursday
7:00 AM - 5:00 PM
Phone: 864.489.3193 | Fax: 864.487.9460

[{"type":"paragraph","subtype":"p","label":"Many times, there is information or a concern that should be shared with our office in writing. This form is designed for you to share your information, concerns, or requests. After reading your concern/request, we will follow up. Thank you.","className":"d-block"},{"type":"text","required":true,"label":"First Name","name":"First-Name","maxlength":250,"className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Last Name","name":"Last-Name","maxlength":250,"className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Last 4 Digits of Social Security Number","name":"SSN","maxlength":250,"className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"email","className":"col-lg-4"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"email-confirmed","className":"col-lg-4"},{"type":"text","subtype":"tel","required":true,"label":"Phone","name":"Phone","className":"col-lg-4"},{"type":"text","label":"Address","name":"Street-Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"City","name":"City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","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"},{"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","selected":true},{"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","label":"Zip","name":"zip-code","maxlength":10,"className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Please State your Concern or Message","className":"d-block"},{"type":"textarea","required":true,"label":"Description of Concern or Issue","name":"Description-of-Concern-or-Issue","subtype":"textarea","rows":10,"className":"d-block"},{"type":"file","label":"Upload image(s) of your concern, if applicable. (Max file size 2MB)","name":"image-of-concern","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"(This form will allow upload of up to 20 files (35 Mb total of all files) in PDF, JPG or JPEG format.) ","className":"d-block"},{"type":"paragraph","subtype":"address","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. ","className":"d-block"}]