Required fields are marked with asterisks (*)

Americans with Disabilities Act Section 504 of the Rehabilitation Act of 1973 Grievance Form

Please fill out this form completely. If you need an accommodation to complete or submit this form, please contact the ADA Coordinator as indicated below:

Drew Schneider, ADA/504 Coordinator
City of Cerritos
18125 Bloomfield Avenue
Cerritos, CA 90703
Phone: (562) 916-1314
TTY: by California Relay at 7-1-1

Complainant:

Name:

Address:

City:

State:

Zip Code:

Home Phone Number:

Business Phone Number:

Person Discriminated Against (if other than the complainant):

Name:

Address:

City:

State:

Zip Code:

Home Phone Number:

Business Phone Number:

Department of person which you believe has discriminated (if known):

Name:

Address:

City:

State:

Zip Code:

Phone Number:

When did the discrimination occur?

Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated:

Have efforts been made to resolve this complaint?

Yes

No

Has the complaint been filed with another bureau, such as the Department of Justice, or any other Federal, State, or local civil rights agency or court?

Yes

No

Do you intend to file with another agency or court?

Yes

No

Additional comments or information:

Signature:

Clear

Date:

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