[Template] Claim Rollback Request

[Ramma]

In order for our and your convenience, please copy paste this template and fill in the information when making your island rollback request topic.
For your topic name, use [Claim Rollback Request]*YourName*

Your Name: 
Claim Owner Name: 
Coordinates: 
Time/Date (Post a time/date when everything was fine): 
Description of Issue: 
Screenshots (Optional):