Title Ii (Ada) And Title Vi Complaint Form (Page 2 of 2) in pdf

Title Ii (Ada) And Title Vi Complaint Form Page 2

List the names and contact information (telephone number, email address, or mailing address) of

persons who may have knowledge of the alleged discrimination:

Name: ____________________________

Contact Information: ______________________________

Name: ____________________________

Contact Information: ______________________________

Name: ____________________________

Contact Information: ______________________________

Have you files this complaint with any other Federal, state, or local agencies, or with any Federal or

state courts? Check all that apply.

 Federal Agency

 Federal Court

 State Agency

 State Court

 Local Agency

Please provide contact information at the agency and/or court where the complaint was filed:

Agency Name: ___________________________________________________________________________

Address: _______________________________________________________________________________

City, State and ZIP Code: ___________________________________________________________________

Telephone Number: ______________________________________________________________________

Contact Person: _________________________________________________________________________

Please sign below. You may attach any materials and/or other information you think to be relevant to

the alleged discrimination event(s).

Complainant Signature

Date

 YES

 NO

Attachments:

Submit this form, completed and signed, as well as any additional materials to:

Kelly Tyra

Director of Administrative Services

KIPDA

11520 Commonwealth Drive

Louisville, Kentucky, 40299

Telephone: 502‐266‐6084

IN TDD: 800‐743‐3333

KY TDD: 800‐648‐6056

Fax: 502‐266‐5047

Email: kelly.tyra@ky.gov

Website:

Title Ii (Ada) And Title Vi Complaint Form Page 2