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ADA Grievance Form
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This form has been modified since it was saved. Please review all fields before submitting.
Your Name
Your Address
Your City
Your State
Your Zip Code
Your Phone Number
(Work/Other)
Person discriminated against (if someone other than yourself):
Name
Address
City
State
Zip Code
Agency and Department or program you allege engaged in discrimination:
Basis for alleged discrimination (check all that apply):
Race/Color
National Origin
Sex
Religion
Age
Disability
Family Status
What date did the alleged discrimination take place?
What date did the alleged discrimination take place?
In your own words, describe the alleged discrimination as clearly as possible, why you believe it happened, and how you were discriminated against. Tell us who was involved, and who you believe was responsible. Be sure to include how other persons were treated differently from you. Please use additional sheets if necessary and attach a copy of written materials that you think supports your complaint.
Please list all witnesses with contact information who may help us investigate your claim.
Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?
Yes
No
If yes, check all that apply:
Federal Agency
Federal Court
State Agency
State Court
Local Agency
Please provide information about a contact person at the agency/court where the complaint was filed:
Name
Address
City
State
Zip Code
Phone Number
We cannot accept a complaint if it has not been signed. Please sign and date this form on the lines shown below:
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
I agree.
Electronic Signature
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Date:
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Date:
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