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2. ADA COMPLAINT FORM
4. City of Apple Valley Public Rights of Way Title II of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 Discrimination Complaint Form.
   Prior to filing a grievance, the public is strongly encouraged to contact the Public Rights of Way ADA Coordinator to discuss any concerns regarding City pedestrian facilities within the public right of way. The ADA Coordinator role is designed to provide a point of contact for the public to address concerns. It is anticipated that most concerns identified will be able to be resolved by the ADA coordinator. Contact information for the ADA coorditator can be found on the City of Apple Valley ADA Transition plan website. Instructions: Please fill out this form completely.
8. Complainant First Name*
9. Complainant Last Name*
11. Address*
13. City*
14. State*
15. Zip*
17. Telephone*
18. E-Mail*
22. Person Discriminated Against: (If other than the complainant)
24. Address
26. City
27. State
28. Zip
30. Telephone
31. E-Mail
35. Government, or organization, or institution which you believe has discriminated
37. Address
39. City
40. State
41. Zip
43. County
44. Telephone
48. When was the issue discovered/when did the problem occur?
    When was the issue discovered/when did the problem occur?
50. Describe the issue in detail, providing the name(s) where possible of the individuals who have been contacted.
52. Have prior efforts been made to resolve this complaint through the grievance procedure?

    1. Yes
    2. No
54. If Yes: what is the status of the grievance?
56. Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?

    1. Yes
    2. No
58. If Yes: Agency or Court:
59. Contact Person:
61. Address
63. City
64. State
65. Zip
67. Telephone Number
68. Date Filed
    Date Filed
72. Do you intend to file with another agency or Court?

    1. Yes
    2. No
74. If Yes: Agency or Court:
76. Address
78. City
79. State
80. Zip
82. Telephone Number
86. NOTICE OF RIGHTS
    In accordance with the Minnesota Government Data Practices Act, the City of Apple Valley is required to inform you of your rights as they pertain to the private information collected from you. Your personal information we collect from you is private. Access to this information is available only to you and the agency collecting the information and other statutorily authorized agencies, unless you or a court authorizes its release. The Minnesota Government Data Practices Act requires that you be informed that the following information, which you are asked to provide, is considered private. The purpose and intended use of the requested information is: To assist City staff and designees to evaluate and respond to accessibility concerns within the public right of way. Authorized persons or agencies with whom this information may be shared include: The City of Apple Valley officials, staff or designee(s) Furnishing the above information is voluntary, but refusal to supply the requested information will mean: The City of Apple Valley staff may be unable to respond to or evaluate your request. MINN.STAT.§13.04(2)
Leave This Blank:


88. 1. Receive an email copy of this form.
89. Email address

    This field is not part of the form submission.

90. Submit

* indicates a required field