ADA Complaint and Procedure Form

Required fields are marked with asterisks (*)

City of Lemon Grove

Instructions: Please fill out this form completely. A printed or typed response is recommended. Sign and return to the address on the last page by email, fax, mail or in person. If you need an accommodation to complete or submit this form, please contact the ADA/504 Coordinator as indicated on this form.

Complainant:

Street Address:

City, State

Zip Code

Telephone:

Business:

Person Discriminated Against: (if other than the complainant)

Address:

City, State

Zip Code

Telephone:

Business:

Department or person which you believe has discriminated (if known):

Name:

Address:

City, State

Zip Code

Telephone:

Date the discrimination occurred:

Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated:

Have efforts been made to resolve this complaint?

Yes

If yes: what efforts have been taken and what is the status of the complaint?

Has the complaint been filed with another bureau, such as the Department of Justice or any other Federal, State, or local civil rights agency or court?

Yes

Agency or Court:

Contact Person:

Address:

City, State, and Zip Code:

Telephone Number:

Date Filed:

Do you intend to file with another agency or court?

Yes

Agency or Court:

Street Address:

City, State, and Zip Code:

Telephone Number:

Additional comments or information:

Signature

Clear

Date:

Return to:

Portland Bates
ADA/504 Coordinator
City of Lemon Grove
3232 Main Street
Lemon Grove, CA 91945
Phone: (619) 825-3827
Fax: (619) 825-3804
Email: pbates@lemongrove.ca.gov
TTY: California Relay at 7-1-1