ADA Grievance Form

Full Name of Grievant (required):

Street Address 1 (required):

Street Address 2:

City (required):

State (required):

Two letter standard state abbreviation

ZIP code (required):

Phone Number (required):

Email (required):

Retype Email (required):

Date (required):

Date the alleged discriminatory act or decision occurred

Court location:

Court location that is the subject of this grievance

Court program or service involved:

Name of the court program or service involved that is the subject of this grievance

Type of accommodation requested:

Description (required):

Describe the alleged discriminatory act or decision (please be specific)

I certify that the above information is accurate (required):