ADA Complaint Form

    Contact Information
    Complainant Information

    Are you filing this complaint on your own behalf? *

    Please explain why you are filing for a third party *

    Have you obtained permission of the aggrieved party you are filing on behalf for? *

    I believe the discrimination I experienced was based on: *

    Accessibility issue
    Discrimination based on disability
    Other

    Date of allegegd discrimination *

    Where did the alleged discrimination take place? *

    Explain as clearly as possible what happened and why you believe that you were discriminated against. Describe all of the persons that were involved. Include the name and contact information of the person(s) who discriminated against you (if known). *

    Please list any and all witnesses’ names and phone numbers / contact info:

    Why type of corrective action would you like to see taken?

    Filing Information

    Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? *

    Where have you previously filed complaints? *

    Agency Contact Information:

    Signature

    You may attach any written materials or other information that you think is relevant to your complaint.
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