Fillable CITY OF SPRINGFIELD ADA COMPLAINT FORM (City of Springfield, Oregon)

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CITY OF SPRINGFIELD ADA COMPLAINT FORM (City of Springfield, Oregon)

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The CITY OF SPRINGFIELD ADA COMPLAINT FORM (City of Springfield, Oregon) form is 3 pages long and contains:

  • 2 signatures
  • 5 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Springfield, Oregon

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Page 1 of 3
CITY OF SPRINGFIELD ADA COMPLAINT FORM
____________________________________________________________
The purpose of this form is to assist you in filing a complaint under the Americans With
Disabilities Act. The ADA prohibits discrimination based on disability.
You may file a complaint against the City, a City contractor, or a City subrecipient of
federal funds. All complaints must be filed in writing within sixty (60) calendar days of
the alleged occurrence of discrimination or when the alleged discrimination became
known to you. Send all complaints to:
City ADA Coordinator
Tom Mugleston
City of Springfield
225 Fifth St.
Springfield, OR 97477
Phone: 541-726-3724
Email: tmugleston@springfield-or.gov
This is an administrative process that does not provide for compensatory or punitive
damages.
The City’s process is not exclusive. A person filing a complaint with the City may also
file a complaint with other state or federal agencies or the courts. Other agencies may
have different time limits for filing complaints.
1. Complainant’s name and contact information:
NAME:
____________________________
ADDRESS: ____________________________
CITY: ____________________________
STATE: ____________________________
ZIP CODE: ____________________________
PHONE: ____________________________
EMAIL: ____________________________
Page 2 of 3
2. Person(s) discriminated against, if different from above:
NAME: ____________________________
ADDRESS: ____________________________
CITY: ____________________________
STATE: ____________________________
ZIP CODE: ____________________________
PHONE: ____________________________
EMAIL: ____________________________
3. When and where did the alleged discrimination occur?
________________________________________________________________
________________________________________________________________
________________________________________________________________
4. Please explain as clearly as possible what occurred, who was involved, why you
believe the incident occurred, and how you (or another) were discriminated
against. If necessary, please use additional sheets of paper and attach a copy of
any written materials pertinent to your complaint.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. Have you filed this complaint with any other federal, state, or local agency, or with
any federal or state court? Please check all that apply.
☐ Federal agency
☐ Federal court
☐ State agency
☐ State court
☐ Local agency
Page 3 of 3
Comments: _______________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_________
Please sign below. You may attach any written materials or other information that
you think is relevant to your complaint.
_______________________________ ________________________________
Complainant Signature Date
Person submitting’s signature if submitted by a person other that the
complainant.
_______________________________ ________________________________
Person submitting complaint Signature Date
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CITY OF SPRINGFIELD ADA COMPLAINT FORM (City of Springfield, Oregon)

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Completed 5 August 2020

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