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2. Filing a complaint

   The following information is needed to assist in processing your complaint/grievance.  Please complete the form and either submit electronically or print, complete and send to City of Grand Junction ATTN: Wanda Winkelmann, 250 N. 5th St. Grand Junction, CO 81501

   This complaint/grievance procedure is solely for facilities, programs, and services owned and/or operated by the City of Grand Junction, CO. If your grievance is related to a non-City owned operation (Title III businesses), please contact the U.S. Department of Justice Information Line at 1-800-514-0301 for assistance.

6. Section 1. Contact Information
8. First Name*
9. Last Name*
11. Phone Number (Home or Cell)*
12. Address
14. City
15. State
16. Zip Code
18. Email Address
22. Section 2. Complainant Information
24. Are you filing this complaint on your own behalf?

    1. Yes
    2. No
26. If yes, skip to Section 3. If no, please provide the following contact information for the person discriminated against:
28. First Name
29. Last Name
31. Phone Number
32. Address
34. City
35. State
36. Zip Code
38. Email Address
42. Section 3. Incident Description
44. Date of the alleged discrimination:
    Date of the alleged discrimination:
46. Location of the alleged discrimination:
48. Explain as clearly as possible what happened and why you believe that you were discriminated against. Describe all of the persons, program and/or services involved. *
50. 26. Please list any and all witnesses’ names and phone numbers/contact information.
52. Have you discussed your complaint with a City employee?

    1. Yes
    2. No
54. If yes, provide name(s) and position(s).
56. 29. Have you filed your complaint with a federal, state, or local agency; or with a federal or state court?

    1. Yes
    2. No
58. Have you filed a complaint with any other federal, state or local agency or with any federal or state court? Check all that apply.

    1. Federal Agency
    2. Federal Court
    3. State Agency
    4. State Court
    5. Local Agency
60. You may attach any written materials or other information you think is relevant to your complaint.

    Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

62. By inputting my name below, I affirm that the above is true to the best of my knowledge, information, and belief.
64. Name*
65. Date*
    Date
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field