Title Ii (Ada) And Title Vi Complaint Form printable pdf download

Title Ii (Ada) And Title Vi Complaint Form

Title II (ADA) and Title VI Complaint Form

Note: We ask for the following information to assist in processing your complaint. If you need assistance

to complete this form, please let us know using the contact information included at the bottom of the

second page. Thank you.

Complainant’s Information

Name: _________________________________________________________________________________

Address: _______________________________________________________________________________

City, State and ZIP Code: ___________________________________________________________________

Telephone (Daytime): ____________________

Telephone Number (Evening): __________________

Person discriminated against (if someone other than the Complainant):

Name: _________________________________________________________________________________

Address: _______________________________________________________________________________

City, State and ZIP Code: ___________________________________________________________________

Telephone (Daytime): ____________________

Telephone Number (Evening): __________________

Which of the following best describes the reason you believe the discrimination took place? Check all that

apply.

 Race/Color (Specify)

 National Origin (Specify)

 Disability

On what date(s) did the alleged discrimination take place?

Describe the alleged discrimination. Explain what happened and who you believe to be responsible. If

additional space is needed, please add additional pages.

Title Ii (Ada) And Title Vi Complaint Form