Jacksonville, TX · Cherokee County
ADA/504 Complaint Form
This form lets a person report alleged disability discrimination involving Jacksonville city programs, activities, services, or employment practices.
What this form is
Use this form to report alleged discrimination and explain what happened, where and when it occurred, who was involved, and why you believe your disability was a factor. It also asks what remedy or action you seek. The form requests the complainant’s contact information, the affected person’s information if different, and a signed statement that the information is true to the signer’s best knowledge.
Who needs it
A person reporting alleged discrimination related to disability in Jacksonville city programs, activities, services, or employment practices can complete this form.
How to submit it
The form directs complaints to the City Secretary in person or by mail at Jacksonville City Hall, 315 S. Ragsdale St, Jacksonville, TX 75766; it also lists [email protected].
About notarization
This document is signed and dated without a notary; it asks the signer to certify the information is true to their best knowledge and mentions no sworn or notarized attachment.
How to submit this form
- 1
Download the Form
Download the Jacksonville ADA/504 Complaint Form PDF.
- 2
Complete the Form
Enter complainant and affected-person information, describe the incident, and state the remedy or action sought.
- 3
Gather Any Extra Pages
Attach additional pages if needed to describe the alleged discrimination.
- 4
Sign and Submit
Sign and date the form, then direct the complaint to the City Secretary in person or by mail at the address provided.
Frequently asked questions
- What is the Jacksonville ADA/504 Complaint Form for?
- It lets a person describe alleged discrimination, provide incident details and contact information, and request a remedy or action.
- Who can use this form?
- A person reporting alleged discrimination related to disability in Jacksonville city programs, activities, services, or employment practices can complete it.
- Do I need a notary for the ADA/504 Complaint Form?
- No. The form has a signature and date section but no notary block; the signer certifies the information is true to their best knowledge.
- How do I submit the ADA/504 Complaint Form?
- The form directs complaints to the City Secretary in person or by mail at Jacksonville City Hall, 315 S. Ragsdale St, Jacksonville, TX 75766. It also lists an email contact.
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.