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2. ADA Grievance Form

   This Form may be used by any individual to file a complaint alleging discrimination on the basis of disability in meetings, services, programs, or activities of the Town of Cumberland under Title II of the ADA. Alternate means of filing a complaint, such as personal interviews or tape recordings, are available upon request for people with disabilities. All complaints will be kept on file for a minimum of 3 years.

4. Filing Date*
5. Date of Alleged Incident*
7. First Name*
8. Last Name*
10. Address
12. City
13. State
14. Zip Code
16. Phone Number*
17. Email Address*
19. The alleged act of discrimination involves which Town department, meeting, agency, or program?*
21. Describe the alleged act of discrimination.*

23. This Complaint Form (or alternate reporting method) should be submitted by the complainant or his/her designee as soon as possible but no later than 120 days after the alleged violation.:

Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field