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)
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:
![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:
Signature: _________________________________________
Date: ________________________________
Return to:
U.S. Department of Justice
Civil Rights Division
950 Pennsylvania Avenue, NW
Disability Rights - NYAV
Washington, D.C. 20530
Paperwork Reduction Act Statement:
A federal agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Public burden for the collection of this information is estimated to average 45 minutes per response. Comments regarding this collection of information should be directed to the Department Clearance Officer, U.S. Department of Justice, Justice Management Division, Office of the Chief Information Officer, Policy and Planning Staff, Two Constitution Square, 145 North Street, N.E., Room 2E–508, Washington, D.C. 20530.
OMB No. 1190-0009. Expiration Date: July 31, 2018.
last updated May 7, 2012