Forms • Lake Stevens, WA • CivicEngage

ADA Grievance

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Complainant Name: *
Designee Name (if applicable):
Designee relationship to Complainant (if applicable):
Contact Address:*
Contact Phone: *
Contact Email:
Detailed description of specific complaint, include all known details such as date, location, circumstance, persons involved, witness:*
Remedy requested, please be specific:*

* indicates required fields.