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2. First Name*
3. Last Name*
5. Phone Number*
6. Email*
8. Mailing Address*
9. City*
11. State*
12. Zip Code*
14. Preparer (If different from Grievant)
15. Relationship to Grievant (If applicable)

17. Nature of Grievance:

19. Please provide a complete description of the specific complain or grievance, including any incident, barrier, or perceived denial of benefit of any service, program, or activity*
21. Please specify any location(s) related to the complaint or grievance (if applicable):*
23. Please state what you think should be done to resolve the complaint or grievance: *
25. Please attach additional pages as needed.
27. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature
30. Date
    Date
32. Upon request, copies of this form will be provided in alternative formats. Please contact the ADA Coordinator for assistance. Savannah Brady (254) 501-7841 or ADAHelp@killeentexas.gov
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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

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