Form 1190-0009 Title II of the Americans with Disabilities Act

Title II of the Americans with Disabilities Act of 1990/Section 504 Rehabilitation Act of 1973 Discrimination Complaint Form

DRS Complaint Form.htm

Title II of the Americans with Disabilities Act of 1990/Section 504 Rehabilitation Act of 1973 Discrimination Compliant Form

OMB: 1190-0009

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Title II Complaint Form U.S. Department of Justice
Civil Rights Division
Disability Rights Section


OMB No. 1190-0009 Exp. Date 04/30/2007

Title II of the Americans with Disabilities Act
Section 504 of the Rehabilitation Act of 1973
Discrimination Complaint Form

Instructions: Please fill out this form completely, in black ink or type. Sign and return to the address on page 3.



Complainant:horizontal divider


Address:horizontal divider


City, State and Zip Code:horizontal divider


Telephone: Home:

Business:

Person Discriminated Against:
(if other than the complainant)horizontal divider


Address:horizontal divider


City, State, and Zip Code:horizontal divider


Telephone: Home:
Business:

Government, or organization, or institution which you believe has discriminated:

Name:horizontal divider


Address:horizontal divider


County:horizontal divider


City:horizontal divider


State and Zip Code:horizontal divider


Telephone Number:horizontal divider


When did the discrimination occur? Date:horizontal divider


Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated (use space on page 3 if necessary):horizontal divider


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Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization, or institution?

Yes______ No______

If yes: what is the status of the grievance?
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Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?

Yes______ No______

If yes:

Agency or Court:horizontal divider


Contact Person:horizontal divider


Address:horizontal divider


City, State, and Zip Code:horizontal divider


Telephone Number:horizontal divider


Date Filed:horizontal divider


Do you intend to file with another agency or court?
Yes______ No______

Agency or Court:horizontal divider


Address:horizontal divider


City, State and Zip Code:horizontal divider


Telephone Number:horizontal divider


Additional space for answers:

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Signature: _________________________________________

Date: ________________________________

Return to:

U.S. Department of Justice
Civil Rights Division
950 Pennsylvania Avenue, NW
Disability Rights - NYAV
Washington, D.C. 20530





last updated April 29, 2005

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