ADA Grievance Form

Name of grievant:

Mailing address of grievant

Email address of grievant

Phone Number of grievant

Are you filing this complaint on your own behalf?

Yes

No

If you answered, please enter the name and relationship of the person you are filing the complaint for:

Have you have obtained permission of the aggrieved party to file this grievance on their behalf?

Yes

No

Date when grievant claims Santa Fe County failed in a program, activity or service to fulfill a requirement of Title II of the A

Location at which grievant claims Santa Fe County failed in a program, activity or service to fulfill a requirement of Title II

Statement of grievance, setting forth a detailed explanation of how Santa Fe County failed in a program, activity or service to

ADA-Grievance Relief Requested or Suggested:

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

Yes

No

If yes, please check all that apply:

Federal Agency

Federal Court

State Agency

State Court

Local Agency

Name all Federal State, or local agencies that apply

Please provide information about a contact person at the agency/court where the complaint was filed.

Name:

Title:

Agency:

Address:

Telephone