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610 Main St
P. O. Box 29
Jasper, IN 47547
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ADA Grievance

 Step 1 of 1

Americans with Disabilities Act Grievance Form

This Grievance Procedure is established to meet the requirements of the Americans with Disabilities Act of 1990 ("ADA"). It may be used by anyone who wishes to file a complaint alleging discrimination on the basis of disability in the provision of services, activities, programs, or benefits.


Please fill out the fields below

* Denotes a required field

Person filling out this form

Second portion of ZIP Code is optional.
Contact Phone Number*
-- ext

Person(s) Discriminated Against (if other than the complainant)

Second portion of ZIP Code is optional.
-- ext

Discriminatory Incident

When did the discrimination occur?*
 When did the discrimination occur?