Atwater, CA · Merced County
ADA Grievance Form
Atwater residents or representatives use this form to describe an Americans with Disabilities Act grievance and request a remedy from the city.
What this form is
This form collects the grievant’s contact information, incident date, time and location, a description of the grievance, witness details, and the requested remedy. A legally authorized representative may file on someone’s behalf, and additional sheets may be attached. The form’s question about involved employees refers to the City of Mission Viejo, despite the Atwater heading.
Who needs it
A person filing an ADA grievance with the city, or a legally authorized representative filing on that person’s behalf, can use this form.
How to submit it
Complete the form in blue or black ink, or type it, then sign and date it. Return it to Mark Pereida, ADA Compliance Officer, at 750 Bellevue Road, Atwater, CA 95301.
About notarization
This form is signed and dated without a notary; attach additional sheets as necessary if more space is needed.
How to submit this form
- 1
Download The Form
Download the ADA Grievance Form.
- 2
Complete The Form
Fill it out in blue or black ink, or type it, including the incident and grievance details.
- 3
Gather Additional Sheets
Attach additional sheets as necessary.
- 4
Sign And Submit
Sign and date the form, then return it to Mark Pereida, ADA Compliance Officer, at 750 Bellevue Road, Atwater, CA 95301.
Frequently asked questions
- Do I need a notary for the ADA Grievance Form?
- No. The form asks the grievant or authorized representative to sign and date it; it does not require notarization. Attach extra sheets if needed.
- How do I submit the ADA Grievance Form?
- Complete it in blue or black ink, or type it, then sign and date it. Return it to Mark Pereida, ADA Compliance Officer, at 750 Bellevue Road, Atwater, CA 95301.
- What information does the form ask for?
- It asks for contact details, incident date, time and location, a description of the grievance, witness information, and the remedy requested.
- Can someone file this grievance for another person?
- Yes. The form says a legally authorized representative filing on someone’s behalf must also provide their name, address, and telephone number.