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1 The City of Marysville Americans with Disabilities Act Public Access Request for Accommodation Form Name: Address: City, State, Zip: Home Phone: Business/Cell Phone: This section to be completed only if the individual requesting the accommodation is not the individual completing this form. Person(s) Requesting Accommodation: (if other than reporting individual) Address: City, State, Zip: Home Phone: Business/Cell Phone: Program/Facility Alleged to Be Inaccessible: Describe the situation or way in which the program is not accessible, providing the name(s) where possible of the individuals who were involved in the situation. (Attach additional pages if necessary.) ---PAGE BREAK--- 2 Explain the nature of the disability you have that limits your ability to participate and how it impairs a major life function. Proposed Accommodation/Resolution: Signature: Date: Send Completed Form to: City of Marysville Teri Lester, ADA Coordinator 1049 State Avenue Marysville, WA 98270 RESERVED FOR ENTITY USE Date Received by ADA Coordinator Date City Response Sent