Fillable CITY OF COOKEVILLE Carl Sells, ADA/504 Coordinator 45 (City of Cookeville, Tennessee)

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CITY OF COOKEVILLE Carl Sells, ADA/504 Coordinator 45 (City of Cookeville, Tennessee)

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BROWSE CITY OF COOKEVILLE, TENNESSEE (TN) FORMS

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CITY OF COOKEVILLE
Carl Sells, ADA/504 Coordinator
45 East Broad Street
Cookeville, TN 38501
Phone: 931-520-5256
Tennessee Relay: 7-1-1
csells@cookeville-tn.gov
AMERICANS WITH DISABILITIES ACT (TITLE II) COMPLAINT FORM
The City of Cookeville ensures that no person or groups of persons shall, on the grounds of race, color, sex, religion, national origin,
age, disability, or genetic information, be
excluded from participation in
,
be denied the benefits of, or be otherwise subjected to
discrimination under any and all programs, services, or activities administered, its recipients, sub-
recipients, and contractors. To
request an accommodation and/or an
alternate format, please contact Carl Sells, ADA/504 Coordinator at 931-520-5256, or
Tennessee Relay by dialing
7-1-1.
I. COMPLAINANT INFORMATION
Name of Complainant: ________________________________________________________________
Last First M
Ad
dress: ___________________________________________________________________________
City: _______________________________ State: _____________________ Zip: _______________
Telephone Number: _______________________ E-mail Address: ____________________________
Preferred Method(s) of Communication: (Check all that apply)
Voice Telephone TTY E-mail US Mail & Other: ______________________________
II. DESCRIBE YOUR COMPLAINT OF DISCRIMINATION BASED UPON DISABILITY.
Be specific and give date (s), time (s), and location (s). Use the reverse side of this sheet or attached
pages, if needed.
III. PERSONS NAMED IN YOUR COMPLAINT. List the names of (or describe) all persons involved
in your complaint. Indicate the job title and City Agency, department or division of City employees, if
possible.
IV. WITNESS TO YOUR COMPLAINT.
List the names of (or describe) all persons involved in your
complaint. Indicate the job title and City Agency, department or division of City employees, if possible.
V. EVIDENCE AND DOCUMENTATION.
List and provide any physical evidence, written or recorded
documents, or any other information that directly supports your specific claim of discrimination.
VI. CASE REMEDY AND/OR RESOLUTION
. What suggested remedies or resolutions are you seeking?
Have you filed or do you intend to file a complaint concerning this incident with any other
agencies (Federal, State or Local)?
Yes
No
If so, please provide the following information:
Agency Name: _______________________________________________________________
Address: _______________________________________________________________
Investigator’s Name: _______________________________________________________________
Telephone Number: _______________________________________________________________
Email Address: _______________________________________________________________
Date Filed: _______________________________________________________________
Complaint Status: _______________________________________________________________
The completed form must be submitted to:
Carl Sells, ADA/504 Coordinator
45 East Broad Street
Cookeville, TN 38501
Phone: 931-520-5256
Tennessee Relay: 7-1-1
csells@cookeville-tn.gov
____
_______________________________________________________________________________
CERTIFICATION: I hereby certify that the information and statements above are true.
Signature: ___________________________________________________ Date: _________________
If person needing accommodation is not the individual completing this form, please provide
Representative’s Name: _______________________________________________________________
Address: ________________________________________ Telephone Number: _________________
____________________________________________________________________________________
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CITY OF COOKEVILLE Carl Sells, ADA504 Coordinator 45 (City of Cookeville, Tennessee)

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Completed 22 January 2021

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