United States Department of Justice, Civil Rights Division
Information and Technical Assistance on the Americans with Disabilities Act
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Americans with Disabilities Act Discrimination Complaints

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.

OMB No. 1190-0009. OMB Control No. 1190-0009. Form Expiration Date: September 30, 2021

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