Name of Person filing grievance or complaint * Address * City * State * Zip Code * Telephone Number Telephone Number or Email Address is required. E-Mail Address E-Mail Address or Telephone Number is required. Person alleging grievance or complaint I certify that I have the authorization from the person with a Mobility Disability to make this request on their behalf. * Yes. Address of Person alleging grievance or complaint City State Zip Code Telephone Number of Person alleging grievance or complaint COMPLAINT City Department, Service, Program Address or Location where grievance or complaint occurred City State Zip Code Telephone Number Date of alleged grievance or complaint * Month MonthAugSepOctNovDecJan Day Day12345678910111213141516171819202122232425262728293031 Year Year20202021 Describe the alleged grievance or complaint. * Has this complaint been filed with the Department of Justice or any other Federal, State, or local civil rights agency or court? * - Select -Yes (If yes, please complete the following section.)No Name of Agency or Court Name of Contact Person Address City State Zip Code Telephone Number Date Filed with Department of Justice or any other Federal, State, or local civil rights agency or court Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Additional space for description of alleged grievance or complaint Information provided in a grievance or complaint may be subject to public disclosure as part of the Willits v. City of Los Angeles Settlement Agreement. Signature * Please sign the Sidewalk Accessibility Grievance Form with your name. By signing this document, you are verifying that the content you are submitting is correct. Signature Date Instructions: If you do not wish to submit your grievance online, please fill out this form in black ink or type, sign and return (mail, fax or e-mail) to the address as listed. Mail, fax or e-mail the completed form to the following address:Department on Disability, Disability Access and Services ADA Compliance Officer201 North Figueroa Street, Suite 100 Los Angeles, CA 90012Fax: (213) 202-2715dod.srpar@lacity.org Please note, this form is for Sidewalk Accessibility Grievances only and not to submit an Access Request repair. If you are a Member of the Settlement Class who wishes to submit a repair request please do so by visiting MyLA311 Access Request. Leave this field blank