ADA Grievance Form Complainant Name * 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 Address Street Apt, floor, suite, etc. City State Zip Phone E-mail Location of Alleged Violation Date of Alleged Violation * (mm/dd/yyyy) 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? *YesNo Contact Person * Contact Address Street Apt, floor, suite, etc. City State Zip Phone E-mail Date Filed * (mm/dd/yyyy) SIGNATURE DATE Please type the above code
