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ADA Complaint Grievance Form

Please allow 1-2 weeks for review.
Submission of this form does not constitute a claim for money or damages under California Government Code sections 900 et seq. or any similar laws. If you want to submit a claim for money or damages against the City, you must submit a separate written claim to the City Clerk.

Name of Complainant

Telephone Number (including area code)

Email Address

Mailing Address - Street Address

Mailing Address - City, State, Zip

Person Preparing Complaint & Relationship (if different from Complainant)

Alleged Violation Date(s)

Alleged Violation Time(s)

Location of Your Complaint or Grievance

Description of Alleged Violation

Requested Remedy for Violation

If You Have Photos of Complaint/Grievance, Please Share Up To 5 Photos

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Allowed extensions pdf, doc, docx, jpg, jpeg, gif, png, tif

Has Your Complaint/Grievance Been Filed With State or Federal Agency?

Yes

Other Comments

Signature

Clear

Date

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