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ADA Grievance Form

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This form has been modified since it was saved. Please review all fields before submitting.

Complainant Name
First Name*
Last Name*
Complainant Address
Street Address*
Apartment, Suite, Etc.
City*
State*
Zip Code*
Phone Number*
Email Address*
Preferred Method of Contact*
1. Phone
1. Email
1. Mail
Person or persons affected by the violation allegation, if different from Complainant.
First Name
Last Name
Street Address
Apartment, Suite, Etc.
City
State
Zip Code
Phone Number
Email Address
Location of Alleged Violation*
Date of Alleged Violation*
Date of Alleged Violation
Additional Location/Date/Time Information
Description of Alleged Violation*
Tell us your concern.
Remedy or Relief Requested*
How can we fix your problem?
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
1. No
If the answer to the above question is yes, please provide a contact person and address below.
First Name
Last Name
Street Address
Apartment, Suite, Etc.
City
State
Zip Code
Phone Number
Email Address
Date Filed with Other Agency/Court
Date Filed with Other Agency/Court
Signature*
Date*
Date
If you have questions or issues with this form, please contact the City Clerk, Katie Nakazono at nakazonok@webstergroves.org or 314-963-5318.
If you are printing this form, please return to:
City Clerk #4 E. Lockwood Webster Groves, MO 63119