Form Center

2. Contact Information
4. Complainant First Name:*
5. Complainant Last Name:*
7. Person Preparing Complaint (if different from Complainant)
9. Relationship to Complainant (if different from Complainant)
11. Address 1*
13. Address 2
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Email Address
24. Complaint
26. Please provide a complete description of the specific complaint or grievance:*
28. Please specify any location(s) related to the complaint or grievance (if applicable): *
30. Please state what you think should be done to resolve the complaint or grievance:
32. Please attach additional images or information as needed.
34. Upon request, assistance can be provided in completing this form, or copies of the form will be provided in alternative formats. Contact the ADA / Section 504 Coordinator, via telephone (209) 333-6711 or via Telecommunication Relay Service (TRS) by dialing 7-1-1, or via e-mail at jrhyne@lodi.gov, or at the following address: Jennifer Rhyne, City of Lodi ADA / Section 504 Coordinator, PO Box 3006, 221 W. Pine Street, Lodi, CA 95240.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field