Title II ADA Complaint Form

Title II ADA Complaint Form
In compliance with Title II of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973, it is the policy of the City of Sammamish (the “City”) to assure that no person with a disability shall be excluded from participation in, be denied the benefits of, or otherwise discriminated against under any of its programs, services, or activities solely based on a disability.

The City will make all reasonable modifications to policies and programs to ensure people with disabilities have an equal opportunity to enjoy its programs, services, and activities. The ADA does not require the City to take any action that would fundamentally alter the nature of its programs or services, or impose an undue financial or administrative burden.

Any person who believes their ADA protection has been violated may file a complaint with the Director of Administrative Services by the following methods:

Email: HR@sammamish.us

Phone: 425-295-0500

Mail:

City of Sammamish

Attn: Director of Administrative Services

801 228 Avenue SE Sammamish, WA 98075

Please answer the following questions:
Name *

Complainant’s First Name Complainant’s Last Name (surname)
Email
Complainant’s Email
example@example.com
Address
Complainant’s Street Address *
Address Line 2
City *
State *
Postal / Zip Code *
Phone
Complainant’s Home Phone Number
Complainant’s Cell Phone Number
ADA Complaint Form (Revised 10/2022)
Title II ADA Complaint Form
Complainant’s Designee Information (if applicable)
Name

Complainant’s Designee First Name Complainant’s Designee Last Name (surname)
Complainant’s Designee Home Phone Number
Complainant’s Designee Cell Phone Number
Complainant’s Designee Email Address (if applicable)
example@example.com
Nature & Location of Complaint
(Please be specific and provide as much information as possible, including the date, time, location, and names of any
My complaint is:
ADA Complaint Form (Revised 10/2022)
Title II ADA Complaint Form
Nature & Location of Complaint (continued)
This is what I think should be done
Washington State Public Records Act
I acknowledge that my submission along with all other written communication and documents shared with members of the city council, city commissioners, or city staff are public records and may subject to disclosure upon request.

By signing this form, I acknowledge receipt of the Washington State Public Records Act Open Records Notification and affirm my signature on this complaint.
Signature
Complainant’s Signature *

Clear
Date *

Month Day Year
Date
Thank you for submitting your comments.

A notice of receipt will be sent to the complainant by email, read receipt requested, or by certified mail, return receipt requested, within five (5) business days.

ADA Complaint Form (Revised 10/2022)
Should be Empty:

Title II ADA Complaint Form

Email

Address

Phone

Title II ADA Complaint Form

Nature & Location of Complaint

Title II ADA Complaint Form

Washington State Public Records Act

Signature