2. ADA Complaint / Grievance Form

4. Please provide your contact information:

6. Complainant Name
8. Street Address & Apt. No.:
10. City:
11. State:
12. Zip:
14. Phone:
15. Email:
17. Please provide a complete description of the specific complaint or grievance:
19. Please specify any location(s) related to the complaint or grievance:
21. Please state what you think should be done to resolve the complaint or grievance:
23. Has this complaint been filed with another federal, state, local agency, or legal entity? If yes, please provide details below:

    1. Yes
    2. No
25. Details:
27. Attach any additional pages as needed
29. Signature:*
30. Date:
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field