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2. The City of Lenoir ADA Transition Plan is on the City website at www.cityoflenoir.com/ada.

4. Grievant's Name
6. Home Address
8. City
9. State
10. Zip Code
12. Home Telephone
13. Business/Cell Phone
15. Email Address

19. This section to be completed only if the aggrieved person is not the individual completing this form.

21. Reporting Individual
23. Person(s) Affected by the Situation
25. Address
27. City
28. State
29. Zip Code
31. Preferred Telephone or Email
35. Program / Activity / Facility Alleged to Be Inaccessible
37. Describe the situation or way in which the program is not accessible, providing the name(s) where possible of the individuals who were involved in the situation (please attach additional pages as needed).
39. Have efforts been made to resolve this complaint through the Request for Accommodation with the ADA Coordinator?

    1. Yes

    1. No
41. If yes, what were the results?
43. Signature

    By typing my name, I am signing this form.

45. ADA Coordinator

    Upon request, reasonable accommodation will be provided in completing this form or copies of the form. Please contact the ADA Compliance Coordinator.

    ADA Coordinator
    David Coffey
    Risk Manager/Purchasing Agent
    City of Lenoir
    801 West Ave NW
    Lenoir, NC 28645
    828-757-2217

    ada@cityoflenoir.com

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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

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