ADA Grievance Form - Town of Fortville

Grievant*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email*
Phone
Person Alleging Violation of Title II
(If other than grievant)
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
Town Department, Bureau, or Service
Address
Phone
When did the alleged violation occur?
MM slash DD slash YYYY
Describe the alleged act(s), providing name(s) where possible of the individuals who allegedly violated Title II.
Has this complaint been filed with the Department of Justice or any other Federal, State, or local civil rights agency or court?
If yes, please complete Section B
- Yes
- No
Section B
Agency or Court
Phone
Contact Person
Date
MM slash DD slash YYYY
Address
Additional space for answers
Signature
Date
MM slash DD slash YYYY