Town of Acton Form Center

Please review the form below and follow the instructions provided. If you have any questions please contact the Town Manager's Office at manager@actonma.gov or 978-929-6611.
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Home Safety Assessment Referral

  1. Provide information about why this person/household is being referred for Home Safety Assessment

  2. Is the resident aware of this referral?
  3. Please type the name and contact information for the person and agency making this referral (Fire Department, COA, Police, Community Svcs, etc)

  4. Leave This Blank:

  5. This field is not part of the form submission.