U.S. Department of Justice
Civil Rights Division
Disability Rights Section

OMB No. 1190-0009

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:_________________________________________________________________________________________

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 (use space on page 3 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:________________________________________________________________________________


Additional space for answers:
_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________



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 October 3, 2007

http://www.usdoj.gov/crt/ada/t2cmpfrm.htm