Date

 *

Date

Your name

 *

Your name

Address

Address

Street address

City

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip code

Contact information

Contact information

Phone numberext.

Email

Person claiming accessibility issue (if different from above)

Name

Name

Contact information

Contact information

Phone numberext.

Email

Complaint

Location of the problem in the right of way
Please include city, street name, intersection (if applicable), facility name and/or location if other than a roadway.

Location of the problem in the right of way Please include city, street name, intersection (if applicable), facility name and/or location if other than a roadway.

What efforts have been made to resolve this complaint?
If you have documentation, copies would be helpful. Examples are letters, email messages, written notes, etc.

What efforts have been made to resolve this complaint? If you have documentation, copies would be helpful. Examples are letters, email messages, written notes, etc.

Has the complaint been filed with any federal or state agency?

Has the complaint been filed with any federal or state agency?

Yes

No

If yes, complete the following:

If yes, complete the following:

Name of agency

Contact name

Date filed

Please attach additional pages if you need more room.

Please attach additional pages if you need more room. Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

---

Notice of rights

In accordance with the Minnesota Government Data Practices Act, the City of St. Louis Park is required to inform you of your rights as they pertain to the private information collected from you. The personal information we collect from you is private. Access to this information is available only to you, the agency collecting the information and other statutorily authorized agencies, unless you or a court authorizes its release.

 

The Minnesota Government Data Practices Act requires that you be informed that the following information, which you are asked to provide, is considered private.

 

The purpose and intended use of the requested information is:

To assist City of St. Louis Park staff and designees to evaluate and respond to accessibility concerns within the public right of way.

 

Authorized persons or agencies with whom this information may be shared include:

City of St. Louis Park officials, staff or designee(s)

 

Furnishing the above information is voluntary, but refusal to supply the requested information will mean:

City of St. Louis Park staff may be unable to respond to or evaluate your request.

 

MINN. STAT. §13.04(2)

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1