Fillable ADA COMPLAINT FORM C ity of Connersville e

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ADA COMPLAINT FORM C ity of Connersville e

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ADA COMPLAINT FORM
Page 1 of 2
NAME
ADDRESS
CITY
STATE ZIP CODE
PHONE NO.
DATE
SELECT EACH OF THE FOLLOWING THAT ARE APPLICABLE TO THE ACCESS BARRIER OR DISCRIMINATION COMPLAINT
PROVIDE A SOLUTION TO THE COMPLAINT
ALTERNATE PHONE NO.
EMAIL ADDRESS
PREFERRED METHOD OF CONTACT
Email
Phone
Mail
PROVIDE A DETAILED EXPLANATION OF THE ACCESSIBILITY BARRIER OR DISCRIMINATION
Public Rights-of-Way
Program
Service
Activity
C
ity of Connersville
Th
e American's with Disabilities Act (ADA) prohibits discrimination on the basis of disability in State and local government, public
accommodations, commercial facilities, transportation, and telecommunications.
This form may be used to file a complaint with the City of Connersville for alleged violations of ADA. If you need assistance
completing this form, please contact us by phone at 765-825-2158 or TTY by dialing 711.
City of Connersville
SIGNATURE DATE
The laws enforced by this department prohibit retaliation or intimidation against anyone because they have either
taken action or participated in action to secure the rights protected by these laws. If you experience retaliation or
intimidation separate from the discrimination alleged in this complaint, or if you have questions regarding the
completion of this form please contact:
City of Connersville
ADA Coordinator: Brad Colter
316 Vine Street
P.O. Box: 325
Connersville, IN 47331
Phone: 765-825-2158
Fax: 765-825-5131
Email: adacoordinator@connersvillein.gov
IF YOU SPOKE TO AN AGENCY OR AGENCIES, WHO WERE THE AGENTS YOU SPOKE WITH?
Yes
No
HAS ANY OTHER AGENCY BEEN CONTACTED REGARDING THIS REQUEST?
IF YES, WHAT AGENCY OR AGENCIES DID YOU CONTACT?
Page 2 of 2
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ADA COMPLAINT FORM C ity of Connersville e

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Completed 22 January 2021

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