2. Instructions:
   Please fill out this form completely. Alternative means of filing a grievance complaint, such as a personal interview or audio recording, will be made available upon request to the ADA Coordinator, whose contact information is listed at the end of this form.
4. Complainant First Name*
5. Complainant Last Name*
7. Street Address*
8. Suite or Apartment Number
10. Mailing Address
    (if different from street address)
12. City*
13. State*
14. Zip Code*
16. Primary Phone*
17. Secondary Phone
19. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
20. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
22. Email Address*
23. Fax Number
25. Person Discriminated Against
    (if other than complainant)
27. First Name
28. Last Name
30. Street Address
32. Suite or Apartment Number
34. Mailing Address
    If different from street address
36. City
37. State
38. Zip Code
40. Primary Phone
41. Secondary Phone
43. Primary Phone Type

    1. Home
    2. Work
    3. Mobile
44. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
46. Email Address
47. Fax Number
49. City Department(s) you believe discriminated*
51. Where alleged discrimination took place*
53. When alleged discrimination took place*
    When alleged discrimination took place

    When alleged discrimination took place
55. Describe the acts of discrimination providing the name(s) where possible of the individuals who allegedly discriminated (if applicable) or facilities in violation of the Americans with Disabilities Act. *
57. Has a 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
59. If yes, with what agency or court?
61. Contact Person
62. Email Address
64. Address
66. City
67. State
68. Zip Code
70. Phone Number
71. Fax Number
73. Do you intend to file with another agency or court? *

    1. Yes
    2. No
75. Agency or Court
77. Address
79. City
80. State
81. Zip Code
83. Phone Number
84. Fax Number
86. Submits to:
    Charles G. Peller, Jr., Engineer/ADA Coordinator, 100 E. Michigan Boulevard, Michigan City, Indiana 46360, cpeller@emichigancity.com, (219) 873-1426 (ext. 333)
88. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
90. Electronic Signature
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit Submit and Print

* indicates a required field