ADA Complaint / Grievance Appeal Form

2. ADA Grievance Form
   Title II of the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973

   Title II of the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973

4. Complainant Name*

6. Designee Preparing Complaint (if different from Complainant)

7. Designee's Relationship to Complainant

9. Contact Information

   Please check one.

   1. Complainant
   2. Designee
11. Street Address*

13. City*

14. State*

15. Zip*

17. Phone number*

18. Email address

22. Please provide a detailed explanation of why you believe the response from the response from the ADA Coordinator did not satisfactorily resolve your complaint.

    Please attach a complete copy of your initial complaint and the response resolution letter from the City's ADA Coordinator.

24. If you have any additional pages, those can be uploaded here.

25. Additional file upload.

27. Appeal remedy requested.

29. E-signature*

30. Today's date*
    Today's date

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field