2. City of Sachse Americans with Disabilities Action Form
   Please complete the below form to provide the City with details related to your concerns.
4. First Name*
5. Last Name*
7. Address1*
9. City*
10. State*
11. Zip*
13. Email Address*
14. Phone Number*
16. Specific location where you experienced a problem with accessing or using a public facility?*
18. Please provide a detailed explanation of the problem. *
20. Category of Problem*

    1. An improvement or accommodation is damaged or improperly built in a way that makes it difficult for me to access or use a public facility.

    1. An improvement or accommodation is missing that would make it possible for me to access or use a public facility.
22. Type of Facility where the Accessibility Issue Exists*

    1. City building
    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
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field