Americans with Disabilities Act (ADA) Complaint Form Please complete this form to file a written complaint with the City of Bellevue ADA Coordinator. Only those fields with an asterisk (*) are required. All other fields are optional. Name First Name: Middle Name: Last Name: Address Address: Suite/Apt/Unit: City: State: - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zipcode: Phone: Alternate Phone: City of Bellevue location involved in complaint: When did the incident occur? Please describe the incident prompting this complaint. Have efforts been made to resolve this issue using City of Bellevue's Accessibility Request Form? Yes No CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.