Ada Complaint Form - Rtcsnv Page 2
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25. E-mail Address: ________________________________
6. Person discriminated against (if other than complainant)
Name:
Address:
City:
State:
Zip Code:
6. Date of incident resulting in discrimination:
7. Describe how you were discriminated against. What happened and who was
responsible? For additional space, attach additional sheets of paper or use back of
form.
8. Did you file this complaint with another federal, state, or local agency; or with a
federal or state court? (Check appropriate space) Yes
No
If answer is yes, check each agency complaint was filed with:
Federal Agency
Federal Court
State Agency
State Court
Local Agency
Other
9. Provide contact person information for the agency you also filed the
complaint with:
Name
Address:
City:
State:
Zip Code:
Date Filed:
10. Sign the complaint in space below. Attach any documents you believe
supports your complaint.
Complainant's Signature
Signature Date
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