U.S. Department of Justice
Civil Rights Division
Disability Rights Section
OMB No. 1190-0009
Title II of the Americans with Disabilities Act
Section 504 of the Rehabilitation Act of 1973
Discrimination Complaint Form
Instructions: Please fill out this form completely, in black ink or type.
Sign and return to the address on page 3.
Complainant:![horizontal divider](images/blac_lin.gif)
Address:![horizontal divider](images/blac_lin.gif)
City, State and Zip Code:![horizontal divider](images/blac_lin.gif)
Telephone: Home:
Business:
Person Discriminated Against:
(if other than the complainant)![horizontal divider](images/blac_lin.gif)
Address:![horizontal divider](images/blac_lin.gif)
City, State, and Zip Code:![horizontal divider](images/blac_lin.gif)
Telephone: Home:
Business:
Government, or organization, or institution which you believe has discriminated:
Name:![horizontal divider](images/blac_lin.gif)
Address:![horizontal divider](images/blac_lin.gif)
County:![horizontal divider](images/blac_lin.gif)
City:![horizontal divider](images/blac_lin.gif)
State and Zip Code:![horizontal divider](images/blac_lin.gif)
Telephone Number:![horizontal divider](images/blac_lin.gif)
When did the discrimination occur? Date:![horizontal divider](images/blac_lin.gif)
Describe the acts of discrimination providing the name(s) where possible
of the individuals who discriminated (use space on page 3 if necessary):![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
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?
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
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:![horizontal divider](images/blac_lin.gif)
Contact Person:![horizontal divider](images/blac_lin.gif)
Address:![horizontal divider](images/blac_lin.gif)
City, State, and Zip Code:![horizontal divider](images/blac_lin.gif)
Telephone Number:![horizontal divider](images/blac_lin.gif)
Date Filed:![horizontal divider](images/blac_lin.gif)
Do you intend to file with another agency or court?
Yes______ No______
Agency or Court:![horizontal divider](images/blac_lin.gif)
Address:![horizontal divider](images/blac_lin.gif)
City, State and Zip Code:![horizontal divider](images/blac_lin.gif)
Telephone Number:![horizontal divider](images/blac_lin.gif)
Additional space for answers:
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
![horizontal divider](images/blac_lin.gif)
Signature: _________________________________________
Date: ________________________________
Return to:
U.S. Department of Justice
Civil Rights Division
950 Pennsylvania Avenue, NW
Disability Rights - NYAV
Washington, D.C. 20530
last updated October 3, 2007