Americans With Disabilities Act Complaint Form
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1New Jersey Judiciary
AMERICANS WITH DISABILITIES ACT
COMPLAINT FORM
COMPLAINANT INFORMATION
LAST NAME
FIRST NAME
MIDDLE NAME
CITY
STATE
ZIP
ADDRESS
DATE
PHONE
Work (optional):
(
)
-
Home:
(
)
-
NUMBER
ALTERNATE CONTACT
LAST NAME
FIRST NAME
MIDDLE NAME
CITY
STATE
ZIP
ADDRESS
PHONE NUMBER
Home:
(
)
-
Work (optional):
(
)
-
COMPLAINT INFORMATION
Appellate
Tax
Municipal
AGENCY ALLEGED TO HAVE
Supreme
Division
Court
Court
DISCRIMINATED / DENIED ACCESS
Court
Superior
Other ______________________________________________________
Court
COURT / DIVISION / UNIT
DATE OF
LOCATION (City / County)
INCIDENT
INCIDENT OR BARRIER
PLEASE DESCRIBE THE PARTICULAR WAY IN WHICH YOU BELIEVE YOU HAVE BEEN DENIED ANY SERVICE, PROGRAM, OR
ACTIVITY OF THE JUDICIARY, OR HAVE OTHERWISE BEEN DISCRIMINATED AGAINST BECAUSE OF, OR RELATED TO, A DISABILITY.
PLEASE SPECIFY DATES, TIMES OF INCIDENTS, AND NAMES OR POSITIONS OF JUDICIARY EMPLOYEES INVOLVED. PLEASE PROVIDE
NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ANY WITNESSES. PLEASE ATTACH ADDITIONAL PAGES IF NECESSARY.
IF YOU NEED HELP IN COMPLETING THIS FORM CONTACT THE LOCAL JUDICIARY ADA COORDINATOR. PLEASE RETURN THIS FORM TO
THE LOCAL ADA COORINATOR OR TO:
CN: 10975 - English
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