Jacksonville, TX · Cherokee County
ADA/504 Complaint Form
This form lets people report alleged disability discrimination and request a remedy from the City of Jacksonville.
What this form is
Use this form to describe alleged discrimination, including when and where it happened, who was involved, and why you believe disability was a factor. It also asks for complainant and affected-person information, any discussion with a city representative, and the remedy or action sought. The form includes a certification and signature line; it does not state a filing deadline or fee.
Who needs it
A person who wants to report alleged discrimination involving a disability and explain the remedy or action they are seeking can complete this form.
How to submit it
Submit in person or by mail to Jacksonville City Hall, 315 S. Ragsdale St., Jacksonville, TX 75766, Attn. Title VI Coordinator, or email [email protected].
About notarization
This complaint form is signed and dated without a notary; it lists no notarized or sworn attachment, so the signer just signs and dates it.
How to submit this form
- 1
Download The Form
Download the ADA/504 Complaint Form PDF.
- 2
Complete The Form
Enter complainant and affected-person details, describe the incident, and state the remedy or action sought.
- 3
Add Any Extra Pages
Attach additional pages if necessary to explain what happened.
- 4
Submit To The City
Submit in person or by mail to Jacksonville City Hall, Attn. Title VI Coordinator, or email the form to the listed address.
Frequently asked questions
- What information does the ADA/504 Complaint Form ask for?
- It asks for contact information, incident date and location, people involved, a description of the alleged discrimination, any discussion with a city representative, and the remedy sought.
- How do I submit the ADA/504 Complaint Form?
- Submit it in person or by mail to Jacksonville City Hall, addressed to the Title VI Coordinator, or email it to [email protected].
- Do I need a notary for the ADA/504 Complaint Form?
- No. The form has a signature and date line but no notary block; it lists no notarized or sworn attachment, so the signer just signs and dates it.
Need something notarized?
This ADA/504 Complaint Form doesn’t need a notary — but Texas residents can notarize other documents online with a commissioned online notary.