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

Paperwork Reduction Act Statement:
A federal agency may not
conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Public
burden for the collection of this information is estimated to average 45 minutes
per response. Comments regarding this collection of information should be
directed to the Department Clearance Officer, U.S. Department of Justice,
Justice Management Division, Office of the Chief Information Officer, Policy and
Planning Staff, Two Constitution Square, 145 North Street, N.E., Room 2E–508,
Washington, D.C. 20530.

OMB No. 1190-0009. Expiration Date: [TBD].

last
updated April 23, 2012