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ADA Complaint Form

Mailing Address:

ADA Coordinator

19 Public Square. Suite 150

Belleville, IL 62220

618-825-4410

Grievance Information *Required Fields




Personal Information  






Terms and Conditions I confirm that:
1) the information provided about the name of the person completing the form is correct,
2) The information provided in the “Describe Grievance” section is, to the best of my knowledge, true and
3) if I completed this form on behalf of the person who was discriminated against, I am authorized to do so.