City Of Jefferson Ada Complaint Form Page 3

V. CASE REMEDY AND/OR RESOLUTION. What remedies or resolutions are you seeking?

CERTIFICATION

I hereby certify that the information and statements provided above are true.

Signature: ________________________________ Date: ______________

If Complainant is not the individual completing this form, please provide:

Representative’s Name: ___________________________________________________

Address: _______________________________________________________________

Telephone Number: ___________________________________

Please submit this form to:

City Counselor/ADA Coordinator

City of Jefferson

320 E. McCarty Street

Jefferson City, MO 65101

Individuals should contact the ADA Coordinator at (573) 634-6570 to request accommodations or alternative formats as

required under the Americans with Disabilities Act. Please allow three business days to process the request.

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Parent category: Business