ADA Grievance Form Complainant Name * First Name MI Last Complainant Address * Street Apt, floor, suite, etc. City State Zip Phone E-mail Person or persons affected by the violation allegation, if different from Complainant. Name First Name MI Last Address Street Apt, floor, suite, etc. City State Zip Phone E-mail Location of Alleged Violation Date of Alleged Violation Description Remedy or Relief which is requested: Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agancy or court? * Yes No Contact Person First Name MI Last Contact Address Street Apt, floor, suite, etc. City State Zip Phone E-mail Date Filed SIGNATURE * DATE Please type the above code
