Americans with Disabilities Act (ADA) Complaint Form Please complete this form to file a written complaint with the City of Bellevue ADA Coordinator. Only those fields with an asterisk (*) are required. All other fields are optional. Name First Name: Middle Name: Last Name: Address Address: Suite/Apt/Unit: City: State: - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zipcode: Phone: Alternate Phone: City of Bellevue location involved in complaint: When did the incident occur? Please describe the incident prompting this complaint. Have efforts been made to resolve this issue using City of Bellevue's Accessibility Request Form? Yes No
