ADA Grievance Form

Citrus County

Board of County Commissioners
DEPARTMENT OF COMMUNITY SERVICES
TRANSIT SERVICES
1300 S. Lecanto Highway, 
Lecanto, FL 34461
Telephone (352) 527-7630 - Facsimile (352) 527-7635

ADA COMPLAINT/GRIEVANCE FORM

Complainant: __________________________________________________________________________________

Person Preparing Complaint (if different from Complainant):_____________________________________________

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Relationship to Complainant (if different from Complainant): ____________________________

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Street Address & Apt. No.:________________________________________________________

City:______________________ State: _____________________ Zip:_____________________

Phone (____)________________ Email:_____________________________________________

Please provide a complete description of the specific complaint or grievance:________________

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Please specify any location(s) related to the complaint or grievance (if applicable):

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Please state what you think should be done to resolve the complaint or grievance:
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Please attach additional pages as needed.
____ Please do not contact me personally.

Signature: ___________________________________________ Date:____________________
Please return to: Carlton Hall, ADA Coordinator
3600 W. Sovereign Path, Suite 212
Lecanto, FL 34461
Carlton.Hall@citrusbocc.com