ADA Accessibility Complaint

Personal Information
Complainant's Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Cell Phone
Home Phone (if different from phone listed above)
Email*
Enter Email Confirm Email
If you require an accessible format(s), check all that apply
If other select, please explain.

Information about the Person Filing the Complaint
Are you filing this complaint for yourself?*
- Yes
- No
Person discriminated against (if other than complainant).*
First Last
Address of person who alleges discrimination*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please explain why you are filing for a third party.*
Please confirm that you have received permission to file this complaint.*
- Yes, I have
- No, I have not

Complaint Details
What is the discrimination based on?*
Please select where this complaint occurred.*
If other was selected, please explain.*
Date of alleged discrimination*
MM slash DD slash YYYY
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons involved and include the name and contact information of the person(s) who discriminated against you (if known), as well as names and contact information of any witnesses.*
If there were any witness to this discrimination allegation, please list their names, addresses and contact information below.

Additional Information
Have you filed this complaint with any other Federal, State or local agency or with any Federal or State court?*
- Yes
- No
Please select any Agency or Court that you have also filed with*
Please list the names of the agency or court that you have filed with as well.*
Please provide any other information relevant to this complaint.*
Certification
I affirm that I have read the above and that the information provided is true to the best of my knowledge, information and belief*
- I agree with the statement above
This complaint was submitted on*
MM slash DD slash YYYY

Personal Information