Purpose: Use this form to file a grievance if you find that the Town of Merrimac has
not provided adequate accommodations for disability.

Instructions: Please complete this form and submit to the contact mentioned below.

Name of Grievant:

Person Preparing Grievance (if different from Grievant):

Full Address of Grievant:

Phone:

Email:

Provide the date(s) the incident occurred:

Please provide a complete description of the specific complaint or grievance:

Please specify any location(s) related to the complaint of grievance (if applicable):

Please state your suggested outcome for resolution of your grievance:

Please attach photos related to the complaint of grievance (if applicable).

Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)

Grievances shall be submitted online or in writing to:
Robert Sinibaldi, ADA Coordinator
The Town of Merrimac
4 School Street
Merrimac, MA 01860
TEL: (978) 346-0525
EMAIL: commissioner@townofmerrimac.com

Hard copies are available at the Town Offices. Upon request, reasonable accommodations will be provided in completing this form.