Required fields are marked with asterisks (*)

Welcome - City of Evans ADA Compliance Form

Please complete the fields below.

Date of Incident Resulting in Complaint

Complainant First Name

Complainant Last Name

Phone

Email address

Address

Person discriminated against (if someone other than complainant)

Address, phone number, email address

Name of agency/facility/department/program against whom complaint is lodged

In your own words, describe the circumstances leading to this complaint. What happened and who was responsible? If possible, provide names of the individuals involved.

If you have not already provided this in response to number 5 above, where did the incident take place? Please provide as much information about the location as possible.

Were there any witnesses to the incident? YES / NO If yes, please provide as much information as possible about any witness(es), including name(s) and contact information.

Have any efforts been made to file or resolve this complaint through the internal grievance procedure of any City of Evans department? YES / NO If yes, what is the status of the grievance?

Have you filed a complaint about this same incident with any other federal, state or local governmental agency or with a federal or state court? Please inform of any and all that apply

Please provide the contact information of the person with the agency/court/other:

By typing your name you recognize that you are signing the complaint form.

Attach any documents you believe support your complaint.

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Welcome - City of Evans ADA Compliance Form