Do I need a notary for the ADA Grievance Form?

No. The grievant or legally authorized representative signs and dates the form; the document does not specify any notarized attachment.

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 ADA Grievance Form request?

It requests contact information, incident date, time and location, a grievance description, witness information, any represented person or group, and the remedy requested.

Atwater, CA · Merced County

No notary required

Americans With Disabilities Act Grievance Form

People who believe the City of Atwater has not complied with the ADA use this form to describe and submit a grievance.

What this form is

The form lets a person or legally authorized representative report a grievance about access to City programs, services, or activities. The city’s procedure says to file as soon as possible, but no more than 60 days after becoming aware of the alleged violation. It asks for contact details, incident information, a description of the grievance, witnesses, and a requested remedy.

Who needs it

A person or legally authorized representative who wants to submit a written ADA grievance to the City of Atwater should use this form.

How to submit it

Complete the form in blue or black ink, or type it, then sign, date, and return it to Mark Pereida, ADA Compliance Officer, 750 Bellevue Road, Atwater, CA 95301. Additional sheets may be attached as necessary.

About notarization

This document is signed without a notary; the grievant or legally authorized representative signs and dates the form, and no notarized attachment is specified.

How to submit this form

1
Download the Form
Download the City of Atwater ADA Grievance Form.
2
Complete the Form
Fill it out in blue or black ink, or type your answers. Include the requested incident, contact, witness, and remedy details.
3
Gather Attachments
Attach additional sheets as necessary to provide information about your grievance.
4
Sign and Submit
Sign and date the form, then return it to Mark Pereida, ADA Compliance Officer, 750 Bellevue Road, Atwater, CA 95301.

Frequently asked questions

Do I need a notary for the ADA Grievance Form?: No. The grievant or legally authorized representative signs and dates the form; the document does not specify any notarized attachment.
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 ADA Grievance Form request?: It requests contact information, incident date, time and location, a grievance description, witness information, any represented person or group, and the remedy requested.
When should I file an ADA grievance?: The city’s procedure says to file as soon as possible, but no more than 60 days after becoming aware of the alleged violation.

Need something notarized?

This Americans With Disabilities Act Grievance Form doesn’t need a notary — but if you have another Atwater form that does, a commissioned online notary can help.