ADA Title II Request for Reasonable Accommodation Form

Step 1 of 1

If you are completing this form for another individual, please submit their contact information and the preferred method of contact. If you are the person who we should contact, please submit your information and your preferred method of contact.

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Person Completing This Form

Check one

Citizen

Representative of Citizen

Today's Date

MonthDay Year,

Please Do Not Complete The Following Field

Citizen Contact Information:

Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone

Telephone Area Code-Telephone Prefix-Telephone Line Number ext Telephone Extension

Email Address

Preferred Method of Contact

Telephone

Mail

Representative of Citizen Contact Information:

Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone

Telephone Area Code-Telephone Prefix-Telephone Line Number ext Telephone Extension

Email Address

Preferred Method of Contact

Telephone

Mail

Accommodation Information:

Please identify the City department or office associated with the program, service, or activity:

Please specify the program, service or activity you are seeking to participate:

Accommodation you are requesting

How will this accommodation assist you?

Please include additional information here: