ADA/Title VI Complaint Form

Supporting Documents

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This Complaint Form is established to meet the requirements of Title II of the Americans with Disabilities Act of 1990 (ADA) and Title VI of the Civil Rights Act of 1964. It may be used by anyone who wishes to file a complaint alleging violation on the basis of race, color, national origin (including Limited English Proficiency, or disability in any program or activity administered by the City of Homer. The City’s Personnel Policy governs employment-related complaints of violation.

Complaints may be submitted using the webform on this page or by downloading the PDF version found at the top of the page and mailing or emailing the completed form to the ADA/Title VI Coordinator at the address found below. 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. The complaint should contain information about the alleged violation such as name, address, phone number of complainant and location, date, and description of the problem. Complaints must be filed within 180 days of the alleged discriminatory act and should be directed to the City Clerk's office.The City of Homer's Complaint Procedures can be found by selecting this link.

If you need assistance, require an accessible format, or have questions about this form, please contact the City of Homer ADA/Title VI Coordinator:

Mail:            City of Homer City Clerk’s Office
                     Attn: ADA/Title VI Compliance
                     491 E Pioneer Avenue
                     Homer, AK 99603

Email: clerk@cityofhomer-ak.gov

Phone: 907-235-8121

at the City Clerk's office at 907-235-8121 or clerk@cityofhomer-ak.gov.

Type of Grievance (check all that apply) *

Accommodation Request

City Program/Service

City Facility Accessibility

Other

Reporting Individual

Full Name *

Mailing Address *

City *

State *

Zip Code *

Phone *

Alternate Phone

Email *

I am reporting:

Authorized Representative of Reporting Individual (if applicable)

Full Name

Mailing Address

City

State

Zip Code

Phone

Alternate Phone

Details of Violation

Date of Incident *

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Per City of Homer Grievance Procedures, grievances should be submitted as soon as possible but no later than 60 calendar days after the alleged violation.

Time of Incident

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Time of Incident AM

Time of Incident PM

Please include an estimated time, if known.

Department/Facility/Location Involved *

Briefly describe the location, or name the department/facility involved

Describe the Violation *

Have attempts been made to resolve the violation through a City Department? *

If yes

I, the reporter/authorized representative for this grievance, warrant the truthfulness of the information provided in this application.

Electronic Signature *

Acknowledgement *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree that I am the person identified above and that I acknowledge and agree to the above Terms of Acceptance.

ADA/Title VI Complaint Form

Supporting Documents

Contact Information