ADA Complaint of Discrimination

ADA Complaint of Discrimination
Alternate means of filing a complaint, such as personal interviews or a taped recording of the complaint, will be made available for persons with disabilities upon request. Please contact Yuu Soubra at 954-344-1144 or ysoubra@coralsprings.gov.

If you are under the age of 18, you must have a parent/guardian submit your application for you.
Are you 18 years of age or older?*

YesNo
Date and time of incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Complainant Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Complainant E-mail Address*
example@example.com
Parent/Guardian E-mail Address*
example@example.com
Complainant Phone Number
Add your best contact to reach you.
Parent/Guardian Phone Number
Add your best contact to reach you.
Complainant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any witnesses
Location of incident*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Discrimination because of*

RaceReligionColorNation OriginSexAgeHandicap/DisabilityIncome StatusRetaliationOther
Please explain how, why, when, and where you believe you were discriminated against. Include as much background information as possible about the alleged acts of discrimination. *
Should be Empty: