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Americans with Disabilities Act Title II Grievance Form

2. Submit a grievance
   The city has developed a grievance procedure to ensure that accessibility concerns are resolved quickly and fairly, as outlined in the American with Disabilities Act (ADA). If you have issues with the form, or to file an oral grievance, please call 763-572-3554.

   The city has developed a grievance procedure to ensure that accessibility concerns are resolved quickly and fairly, as outlined in the American with Disabilities Act (ADA). If you have issues with the form, or to file an oral grievance, please call 763-572-3554.

4. Would you prefer to fill out a paper form?
   Download the form.

6. Compliant - person filing grievance

8. Name:

9. Date:
   Date:

   Date:

11. Street address:

12. City:

14. State:
    -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

15. Zip code:

17. Phone:

18. Email:

20. Person claiming accessibility issue (if different from above)

22. Name:

24. Phone number:

25. Email:

27. Compliant

29. Where is the location of the problem? (Please include city, street name, intersection(if applicable), facility name and/or location if other than a roadway.)

31. What efforts have been made to resolve this compliant?

33. If you have documentation, copies would be helpful. Please upload any letters, email messages, written notes, etc.

35. File upload

37. File upload

39. Has the compliant been filed with any federal or state agency?
    -- Select One --YesNo

41. Name of agency:

43. Contact name:

44. Date filed:
    Date filed:

    Date filed:

Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field