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Morgan County Disability Access Office P.O. Box 1357 150 East Washington Street, Suite 200 Madison, Georgia 30650 (706) 342-4373 Office (706) 343-6455 Fax ADA Formal Written Complaint Please print legibly. Reporting Individual: Date of Request: Address: City, State and Zip: Telephone Number: Business Phone: Other Contact Information: If person needing accommodation is not the individual completing this form, please complete below: Name: Telephone Number: Other Contact Information: Program/Facility to be Inaccessible: When did the situation occur (date)? 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, and any documentation or photographs supporting the incident: Have efforts been made to resolve this complaint through the Request for Accommodation with the ADA Coordinator? Yes No If yes, what were the results? How do you suggest this issue be remedied? Signature: Date: Planning and Development Representative: Date: