Grievant: *
Grievant:
Your Name
Address
Address
Phone
Phone
Person Alleging Violation of Title II
Person Alleging Violation of Title II
(If other than grievant)
Address
Address
Phone
Phone
Phone
Phone
When did the alleged violation occur?
When did the alleged violation occur?
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
Section B
Phone
Phone
Date
Date
Signature/Name:
Signature/Name:
Date
Date