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Instructions: Please fill out this form completely, in black ink or =
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Sign and return to the address on page 3. =
Return to: U.S. Department of Justice OMB No. 1190-0009. Expiration Date: [TBD].
Complainant:
Address:
City, State and Zip Code:
Telephone: Home:=20
Business:
Person Discriminated Against: =
(if=20
other than the complainant)
Address:
City, State, and Zip Code:
Telephone: Home:=20
Business:
Government, or organization, or=20
institution which you believe has discriminated:
Name:
Address:
County:
City:
State and Zip Code:
Telephone Number:
When did the discrimination occur? Date:
Describe the acts of discrimination providing the =
name(s)=20
where possible of the individuals who discriminated (use space on page 3 =
if=20
necessary):
Have efforts been made to resolve this complaint =
through=20
the internal grievance procedure of the government, organization, or=20
institution?
Yes______ No______
If yes: what is the status =
of the=20
grievance?
Has the complaint been filed with another =
bureau of the=20
Department of Justice or any other Federal, State, or local civil rights =
agency=20
or court?
Yes______ No______
If yes:
Agency or =
Court:
Contact Person:
Address:
City, State, and Zip Code:
Telephone Number:
Date Filed:
Do=20
you intend to file with another agency or court?
Yes______ No______
Agency or =
Court:
Address:
City, State and Zip Code:
Telephone Number:
Additional space for answers:
Signature:=20
_________________________________________
Date:=20
________________________________
Civil Rights Division
950 =
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Disability Rights - NYAV
Washington, D.C. 20530
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Planning Staff, Two Constitution Square, 145 North Street, N.E., Room =
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Washington, D.C. 20530. ![3D""](3D"http://www.ada.gov/images/teeltow2.gif"=20)
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updated April 23, 2012