File a Title II ADA Administration Complaint

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


Instructions: Print and fill out this form completely, in black ink or type. Sign and return to the address at the bottom of this page.


Complainant: ___________________________________

Address: ______________________________________

City, State and Zip Code: ____________________________________

Telephone: _________________________

Home: _____________________________

Business: __________________________




Person Discriminated Against: ___________________________________
(if other than the complainant)

Address: ___________________________

City, State, and Zip Code: ___________________________________

Telephone: ______________________________

Home: ___________________________

Business: ___________________________




Government, or organization, or 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) where possible of the individuals who discriminated (add extra pages if necessary):







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?







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: ____________________________________________

Contact Person: ____________________________________________

Address: ____________________________________________

City, State, and Zip Code: ____________________________________________

Telephone Number: ____________________________________________

Date Filed: ____________________________________________



Do you intend to file with another agency or court?

Yes______ No______

Agency or Court: ____________________________________________

Address: ____________________________________________

City, State and Zip Code: ____________________________________________

Telephone Number: ____________________________________________




Signature: _________________________________________

Date: ________________________________


Return to:

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