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 Clerk’s Office, 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. Date I received written response from ADA coordinator*
    Date I received written response from ADA coordinator
27. Reasons why I disagree with decision of ADA coordinator*
29. How I believe compliance can be achieved and this matter resolved
31. Submits to:
    Michigan City Clerk’s Office, 100 E. Michigan Boulevard, Michigan City, Indiana 46360, Attn: Gale Neulieb, galen@emichigancity.com, (219) 873-1410 (telephone)
33. 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.
35. Electronic Signature
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field