File a Title II ADA Administration Complaint
Title II of the Americans with Disabilities Act
Section 504 of the Rehabilitation Act of 1973
Discrimination Complaint Form
Instructions: Print and fill out this form completely, in black ink or type. Sign and return to the address at the bottom of this page.
Complainant:___________________________________
Address:______________________________________
City, State and Zip Code:____________________________________
Telephone:_________________________
Home:_____________________________
Business:__________________________
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Person Discriminated Against:___________________________________
(if other than the complainant)
Address:___________________________
City, State, and Zip Code:___________________________________
Telephone:______________________________
Home:___________________________
Business:___________________________
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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 (add extra pages 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:____________________________________________
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Signature: _________________________________________
Date: ________________________________
Return to:
U.S. Department of JusticeCivil Rights Division
950 Pennsylvania Avenue, NW
Disability Rights - NYAV
Washington, D.C. 20530
