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2. This Americans with Disabilities Act Grievance Procedure and Complaint Form is available in alternative formats upon request. Alternative formats include audio-format, braille, large print, electronic text, etc. Please contact the City Clerk and allow 7-10 days for production of the material in an alternative format.

4. Lezli Merritt - City Clerk and ADA Coordinator. Email or call (352) 245-7021 ext 2109

6. The City of Belleview will make every reasonable effort to ensure that confidentiality is maintained throughout the complaint and investigation process, to the extent consistent with the law, adequate investigation, and appropriate corrective action. This means that the City of Belleview will share any sensitive information you provide here only on a need-to-know basis.

8. Name
9. Address
11. Telephone Number
12. Email Address
14. 1. Describe the City of Belleview alleged violation of access requirements, or discriminatory action, in enough detail so that the nature of your grievance can be clearly understood.
16. 2. Give the date(s), time(s) and location(s) of the incident(s) or observation(s) you are reporting.
18. 3. If the incident involves a City of Belleview employee(s), please provide their name(s), if known.
20. 4. If the grievance involves physical access to a City of Belleview public facility, land, or right-of-way, please provide the specific address(es) of those locations, if known.
22. 5. Give the name(s) and address(es), if known, of any witnesses to the access violation or alleged discrimination:
24. 6. If this complaint is filed on behalf of a second person, or on behalf of a group of people, please provide the names and addresses of all of the grievants, if possible:
26. 7. What action do you want taken to correct the alleged access violation or discrimination?
28. 8. Is there any other information you want the City of Belleview to know concerning your grievance?
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

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