Blue sky view of red mountains in Apache County

ADA Grievance Form

Today's Date

Your First & Last Name

First Last

Address/PO Box

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Your Phone Number

Your Email Address

Nature of Disability

Court/Division Alleged to have Denied Access

Location of Alleged Discrimination

Date of Alleged Discrimination (mm/dd/yyyy)

Time of Alleged Discrimination

Please describe the particular way in which you believe you have been denied the benefit, service, program, or activity of the Superior Court, or have otherwise been subject to discrimination as a person with a disability by the Superior Court.

Please state, if known, the names or positions of any Superior Court employees involved in the incident, as well as names, addresses, and telephone numbers of any witnesses to any such incident, if necessary.

Fountain pen on top of a spiral notebook