Complaint Form

Title II -  Complaint Form

U.S. Department of Justice
Civil Rights Division
Disability Rights Section
________________________________________

OMB No. 1190-0009
Title II of the Americans with Disabilities Act
Section 504 of the Rehabilitation Act of 1973
Discrimination Complaint Form
Instructions: Please fill out this form completely, in black ink or type. Sign and return to the address on page 3.

Complainant:_________________________________

Address:_____________________________________
City, State and Zip Code:_________________________
Telephone: Home: _____________________________

Business:____________________________________

Person Discriminated Against:(if other than the complainant)
__________________________________________
Address:___________________________________
City, State, and Zip Code:_____________________
Telephone: Home: ___________________________
Business:___________________________________

Government, or organization, or institution which you believe has discriminated:
Name:_______________________________________
Address:_____________________________________
County:______________________________________
City:_________________________________________
State and Zip Code:_____________________________

Telephone Number:_____________________________

When did the discrimination occur? Date: ____________

Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated (use space on page 3 if necessary):

__________________________________________
__________________________________________
__________________________________________
Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization, or institution?

Yes_____ No______

If yes: what is the status of the grievance?
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?

Yes______ No______
If yes:
Agency or Court__________________________________

Contact Person:__________________________________

Address:________________________________________
City, State, and Zip Code:___________________________
Telephone Number:________________________________

Date Filed:______________________________________

Do you intend to file with another agency or court?

Yes______ No______

Agency or Court: ________________________________
Address: _______________________________________
City, State and Zip Code: __________________________
Telephone Number:  ______________________________

Additional space for answers:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

 

Signature: _________________________________

Date:_____________________________________

Return to:
U.S. Department of Justice
Civil Rights Division
950 Pennsylvania Avenue, NW
Disability Rights - NYAV
Washington, D.C. 20530

________________________________________
last updated October 3, 2007

http://www.ada.gov/t2cmpfrm.htm

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