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2. You may use this form or a letter, email, or phone call with the same information to the ADA Coordinator at ada@carrboronc.gov or 919-913-3193. Once submitted, the ADA Coordinator may contact you to confirm receipt and request any additional information needed before processing the complaint.
6. First Name*
7. Last Name*
9. Address1
11. Address2
13. City
14. State
15. Zip
17. Phone Number*
18. Email*
22. Are you filing this complaint on behalf of someone else?*

    If yes, please explain why you are filing on behalf of the individual and describe your relationship to them.

26. Date and location of the alleged action(s).*

    Include the earliest and most recent dates, if applicable.

27. Name(s) of individual(s) or Town department responsible for the action(s), if applicable.*
29. Please describe the alleged action, explaining what happened and why you believe it was prohibited.*
31. Were you retaliated against?

    Federal law prohibits intimidation or retaliation against a complainant or anyone assisting them. If you believe you experienced retaliation separate from the discrimination described above, explain the circumstances above, including what action you took that you believe prompted the retaliation.

33. Briefly explain what remedy you are seeking for the alleged action.
37. Please provide any names and contact information for any witnesses or others we may contact for additional details about your complaint.
39. Have you discussed this complaint with any Town of Carrboro representative?

    If yes, please provide their name.

41. Have you filed this complaint with any other federal, state, or local agency?

    If yes, please provide the name of that agency, and any available contact information for the individual who handled the complaint.

45. Please upload any supporting documentation here.
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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

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