Americans with Disabilities Act Title II Grievance Form
Today’s Date:
Complainant Name:
Address:
City, State, Zip:
Telephone and email:
Individual discriminated against (if other than complainant):
Name:
Address:
City, State, Zip:
Telephone and email:
Alleged violation: Date(s) of occurrence:
Describe violation and City Department involved:
What efforts have been made to resolve this complaint using the internal grievance procedures of the City
Department?
If you have documentation, copies would be helpful. Examples are letters, email messages, written notes, etc.
Has complaint been filed with State or Federal Agency? Yes No
Name of Agency: Date Filed:
Contact Person:
TENNESSEN WARNING
The data you supply on this form will be used to process the ADA grievance you are submitting. You are not legally required to
provide this data, but we will not be able to process the ADA grievance without it. The data will constitute a public record if
and when the ADA grievance is submitted.
Signature:
Date:
Please attach additional pages if you need more room. When complete, please scan and email to
jlenzmeier@coonrapidsmn.gov. Or mail completed form to City Hall, 11155 Robinson Drive, Coon Rapids, MN 55433
click to sign
signature
click to edit
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