ADA Grievance Form

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CITY OF TRINIDAD, COLORADO ADA GRIEVANCE FORM

ADA Coordinator P. O. Box 880 / 135 N. Animas Street Trinidad, CO 81082 Upon request, reasonable accommodation will be provided in completing this form, or copies of the form will be provided in alternative formats. Contact the ADA Coordinator at the address listed above, via telephone (719) 846-9843 ext. 126 or via TTY (719) 846-4441 (Police Dept.)

Complainant:

Person Preparing Complaint (if different from Complainant):

Relationship to Complainant (if different from Complainant):

Address

City

State

Zip Code

Phone

Please provide a complete description of the specific complaint or grievance:

Please specify any location(s) related to the complaint or grievance (if applicable):

Please state what you think should be done to resolve the complaint or grievance:

Please attach additional pages as needed.

Please do not contact me personally

E-Signature

Date

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