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2. Mail or fax this form to:
   ADA Coordinator
   DeeAnne Byrne-Scott
   City of Troy
   116 E. Market St.
   Troy, IL 62294
   Fx: 618-667-4009
6. Today's Date
8. First Name
9. Last Name
11. Address1
13. Address2
15. City
16. State
17. Zip
19. Phone Number
21. Alternate Contact Person (Name, Address, and Telephone Number)
25. Agency alleged to have denied access:
    City of Troy Administration Office
    116 E. Market St.
    Troy, IL 62294
27. I was denied access on: (date)
29. My disability is:
31. This problem is:

    1. Temporary

    1. Permanent
33. I am seeking access to the City of Troy which I haven't been able to enter because I need an accommodation:
35. The accommodation I seek:
37. Please describe the particular way in which you believe you have been denied the benefits of any services, program or activity or have otherwise been subjected to discrimination. Please specify dates, times, and places of incidents and name and/or positions of agency employees involved. If any, as well as names, addresses, and telephone numbers of any eyewitnesses to any such incident. Attach additional pages if necessary. Include a description of the way in which you feel access may be had to the benefits described above, or the way in which accommodation could be provided to allow access.
41. Mail or fax this form to:
    ADA Coordinator
    DeeAnne Byrne-Scott
    City of Troy
    116 E. Market St.
    Troy, IL 62294
    Fx: 618-667-4009
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