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2. First Name*
3. Last Name*
5. Street Number*
6. Street Name*
7. Street Type*
8. Apt #*
10. City*
11. State*
12. Zip*
14. Email Address*
15. Phone Number*
17. Preferred Contact Method

    1. Email
    2. Mail
    3. Phone
19. What facility or service did you experience a problem accessing?*
21. Please provide a detailed description of the problem.*
23. Category of Problem*

    1. An improvement or accommodation is missing, 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 participate in a city service or program.
    3. An improvement or accommodation is missing, damaged or improperly built in a way that makes it difficult for me to access or use public infrastructure such as a sidewalk or curb ramp.
    4. An improvement or accommodation is missing that would make it possible for me to access city communications.
25. Type of Facility where the Accessibility Issue Exists*

    1. City building (i.e. Municipal Complex, Fire Station)
    2. City park (including playground equipment and/or parking lot)
    3. City street or sidewalk, including traffic signals and pedestrian crossing signals
    4. Other, not listed
27. Name or address of facility for which the accommodation is being requested
28. Name of program, service or activity for which the accommodation is being requested.
30. Date of program, service or activity (if applicable)
32. Describe the specific improvements or accommodation(s) you are requesting and how this accommodation will assist you.
34. Online Submission Notification

    All requests submitted online are sent directly to Kimberly Winarski, the City of Anna ADA Coordinator for action. The City will provide written acknowledgment of your request within 15 days. A written response to your request will be provided no later than 21 days from receipt of the request.

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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