Updated 5/1/18
The Americans with Disabilities Act
REASONABLE ACCOMMODATION REQUEST FORM
Date: Name: _______________________________
Street Address: _________________________________________________________
City: ______________
_______ State _________________ Zip Code: ___________
Preferr
ed Method of Contact:
Email: _____
__________________________________________________________
Phone (day): ________
_____________
Please specify the program, service, activity, policy, or communication for which you
seek accommodation:
Request for Reasonable Accommodation
1. I am requesting accommodation (check all that apply):
___ that will allow me to participate in a program or activity offered by the City of San
Marcos. Please specify the program or activity:
____ by asking for an exception to a rule, policy, or procedure. Please specify the
rule, policy, or procedure:
____ other - please specify (for example, the way that the City of San Marcos
communicates with you):
2. Describe the accommodation you are requesting:
3. Describe how this accommodation will assist you. (Please attach additional
sheets as necessary):
Return to: City of San Marcos, ADA Coordinator, 630 E Hopkins, San Marcos, TX 78666,
Fax: (512)393-8074 or email ADARequest@sanmarcostx.gov.
Thank you for completing this form. Your request will be addressed. Should you be
unsatisfied with the response to your request you may appeal to the ADA Coordinator at
512-393-8000 within 15 business days of receiving the response. For information on the
“
ADA Reasonable Accommodation”, please visit www.sanmarcostx.gov.
