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2. Name*
4. Address
6. City
7. State
8. Zip Code
10. Phone Number*
12. Email Address*
14. Are you a person with a disability?*

    1. Yes
    2. No
16. If "YES" please list the functional limitations due to your disability.
18. If "NO" and you are submitting this grievance on behalf of a person with a disability, please provide the name, address, phone number, and email address, and the nature of your relationship with that person, and describe that person’s functional limitations due to a disability.
20. PLEASE CHECK ALL THAT APPLY:*

    1. I believe I was discriminated against based on a disability.
    2. I believe I was denied a reasonable accommodation.
    3. I believe I was excluded from participation in a city service, program, or activity.
    4. I believe I was denied the benefits of a city service, program, or activity.
22. Please explain as clearly as possible what happened and the relevant date(s), time(s), and location. Please also provide the name, addresses, and phone numbers of all persons (including City employees) who witnessed or were involved with the incident(s).*
24. If you have any documents (for example: emails, letters, photographs) that you believe are relevant to your grievance, please attach copies.
26. Have you previously filed a disability-related grievance with the City of Jacksonville Beach?*

    1. Yes
    2. No
28. If "YES" please state the date:
30. Have you previously filed a disability-related complaint about the City of Jacksonville Beach with a court or any other government agency?*

    1. Yes
    2. No
32. If “YES” please identify the court or government agency and state the date of the complaint:
34. Certification*

    1. I HEREBY CERTIFY that the statements provided on this form, and any attachments, are true and correct.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field