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American with Disabilities Act (ADA) Grievance Form

Complainant:

Relationship to Individual Discriminated Against:

Phone Number:

Email:

Individual Discriminated Against:

Phone Number:

Email:

Alleged Violation: Date(s) and Place of Occurrence:

Description of Violation and City Department Involved:

Requested Action by City to Correct Violation:

Has Complaint been Filed with State or Federal Agency?

Yes

If Yes, Name of Agency:

Date Filed:

Contact Person:

Complainant Signature:

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Date: