Welcome to the Ward 66 Community Support System Form - An initiative by Councillor Da Rocha, in order to better serve his community.

In order to streamline support requests and better serve you, Councillor Da Rocha is requesting community participation, in the form of sending him support requests via the form on this web page.

Community members of ward 66 may use this support system, to report problems and issues to the councillor for his attention. In order for the Councillor to assist you, please be sure to furnish the exact street address of where the problem is being experienced and if possible, include a photograph of the issue as well.

DO NOT use this form to report issues related to Burst Pipes or Power Outages, as these two issues are urgent issues, requiring immediate attention. To report Power Outages or Burst Pipes, instead PLEASE SMS the councillor on tel: 083 447 3648

Your Contact Details:

First Name (required)

Last Name (required)

Physical Address(required)

Cellphone Number(required)

Email Address(required)

Support Issue Details:

Please Describe Your Issue and make sure to give me the EXACT street address (house/apartment/building number, street name & suburb) of where the issue is to be found.

DO NOT use this form to report issues related to Burst Pipes or Power Outages, as these two issues are urgent issues, requiring immediate attention. To report Power Outages or Burst Pipes, instead PLEASE SMS the councillor on tel: 083 447 3648

Issue Subject (required)

Physical Address where the issue is to be found (required)

Issue Detailed Description (required)

If you have a photograph of the issue, please feel free to upload it, by making use of the upload feature below. The following file formats are allowed: jpg, jpeg, png, pdf. Please note that there is a file size upload limit of 10mb per file.

Upload an image of the Issue

Electronic signature acceptance(required)