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Americans with Disabilities Act Discrimination Complaints

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

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









(preferred)


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.





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