2. First Name*
3. Last Name*
4. Phone Number
   xxx-xxx-xxxx
5. Email
7. Street Address
8. City
9. State
10. Zipcode
12. Representative Information
    If a Representative is completing this form, provide the Representative's name and contact information
14. Please note: All complaints/grievances are public records. Alternative means of filing complaints, such as personal interviews or a tape recording of the complaint will be made available for persons with disabilities upon request.
    Please answer all of the following questions:
16. Describe in detail the event or problem for which you are seeking ADA relief. Provide the names of all individuals who were involved:
18. If your complaint involves a specific event, when and where did the incident occur?
20. If this is a general request for an accommodation, describe the functional limitations caused by your disability for which you are requesting this accommodation.
22. Describe any accommodations that you believe would minimize or eliminate the barriers to your participation in the County's services, activities, programs, or benefits:
24. If you need an accommodation to meet with the ADA Coordinator, please describe what that accommodation is:
26. Signature
    Type name
27. Date
29. This form will be submitted to the ADA Coordinator:
    Christine Cambareri Kay, Division Director
    Citizens Services Division
    Frederick County Government
    401 Sagner Avenue, Frederick, MD 21701
    301-600-1454 Email: ADA@frederickcountymd.gov
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31. 1. Receive an email copy of this form.
32. Email address

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33. Submit

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