ADA Title II Grievance

2. Complainant's Name

4. First Name*

5. Last Name*

7. Address*

9. City*

10. State*

11. Zip Code*

13. Phone Number

14. Email Address

18. Individual Discriminated Against (if other than complainant) Information

20. First Name

21. Last Name

23. Address

25. City

26. State

27. Zip Code

29. Phone Number

30. Email Address

34. Alleged Violation

36. Date of Occurrence*
    Date of Occurrence

38. Describe the Violation and City Department Involved:*

40. What efforts have been made to resolve this complaint using the internal grievance procedures of the City Department?*

44. Documentation
    If you have any documentation (letters, emails, messages, written notes, etc.), please upload them.

    If you have any documentation (letters, emails, messages, written notes, etc.), please upload them.

46. Supporting Document 1

48. Supporting Document 2

50. Supporting Document 3

54. Other Filing of This Incident

56. Has this complaint been filed with a State or Federal Agency?*

    1. Yes
    2. No

58. If yes, can you provide additional details?

60. Date Filed
    Date Filed

61. Contact Person

Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field