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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip*
11. Phone Number*
12. Email Address*
14. Specific location where you experienced a problem with accessing or using a public facility:*
16. What exactly is the problem?*
18. Nature of the Problem:*

    1. An improvement or accommodation is damaged or improperly built in a way that makes it difficult for me to access or use a public facility.
    2. An improvement or accommodation is missing that would make it possible for me to access or use a public facility.
20. The public facility that is difficult or unable to access or use is:

    1. A City building (Problems with accessing or using buildings under the control of a school district or a county government should be reported directly to those entities.)
    2. A park, including play equipment
    3. A street or sidewalk, including traffic signals and pedestrian crossing signals
    4. Other not included above – e. g. public information kiosks
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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