United States Department of Justice, Civil Rights Division
Information and Technical Assistance on the Americans with Disabilities Act
2010 Regulations
2010 Design Standards
Technical Assistance Materials
   Other languages: Español

Americans with Disabilities Act Discrimination Complaint Form

Please complete this form. Fields marked with an asterisk (*) are required. If you wish to send attachments, you may do so after submitting this form. You will receive a response email after you have submitted this form that will contain a complaint reference number and instructions on how you may send attachments.

Person filling out this form


Person(s) Discriminated Against (if other than the complainant)
Discriminatory incident

Government, organization, institution or business which you believe has discriminated

When did the discrimination occur?

4000 characters remaining.

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 30 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: September 30, 2021

Privacy Act Notice