Americans with Disabilities Act (ADA) Title II Grievance Form
Grievant Information
Grievant Name: _____ Home Phone (include area code): _____
Address: _____ Business Phone (include area code): _____
Mobile Phone (include area code): _____
Alternative Contact Person (other than Grievant)
Name: _____ Home Phone (include area code): _____
Address: _____ Business Phone (include area code): _____
Relationship To Client: _____
Court Service, Program or Facility Allegedly in Violation
Date and Location of Alleged Violation (dd/mm/yyyy) ________________________
Description of Alleged Violation and Requested Remedy
Has this case been filed with the Department of Justice or other government agency or court?
Yes ☐ No ☐ If You Answered "YES" to the Previous Question, Complete the Following
Agency or Court: _____ Contact Person: _____
Address: _____ Phone (include area code): _____
Date Filed: _____
Other Comments
Signature: _____ Date: _____