Ada Complaint Form - Asheville (Page 2 of 3) in pdf

Ada Complaint Form - Asheville Page 2

Attachment A

Incident description continued:

_____

_______________________________________________________________________

__________________________________________________________

_________________________________________________________

____

________________________________________________________________________

__________________________________________________________

Have you filed a complaint with any other federal, state or local agencies? (Circle one)

Yes / No

If so, list agency or agencies and contact information below:

Agency:

Contact Name:

Street Address, City, State & Zip Code:

Phone:

Agency:

Contact Name:

Street Address, City, State & Zip Code:

Phone:

I affirm that I have read the above charge and that it is true to the best of my knowledge,

information and belief.

______________________________________________________________________________

Complainants Signature:

Date:

Please return the completed and signed form to: City of Asheville (COA), Transportation

Department, Transportation Planning Management Division, 70 Court Plaza, Asheville

28801.

Complainants have the right to submit their complaint at any point in the process directly

to: FTA (Federal Transit Administration), Office of Civil Rights Region IV, 230 Peachtree,

NW, Suite 800, Atlanta, GA 30303, telephone (404) 865-5600.

City of Asheville Use Only:

Print or Type Name of Complainant

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Ada Complaint Form - Asheville Page 2