U.S. Department of Justice
Civil Rights Division
Disability Rights Section

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

Americans with Disabilities Act Discrimination Complaint Form

Instructions: Please fill out this form completely, in black ink or type. Sign and return to the address on page 3.

Complainant:horizontal divider

Address:horizontal divider

City, State and Zip Code:horizontal divider

Telephone: Home:

Business:

Person Discriminated Against:

(if other than the complainant)horizontal divider Address:horizontal divider City, State, and Zip Code:horizontal divider Telephone: Home:

Business:

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

Name:horizontal divider

Address:horizontal divider

County:horizontal divider

City:horizontal divider

State and Zip Code:horizontal divider

Telephone Number:horizontal divider

When did the discrimination occur? Date:horizontal divider

Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated (use space on page 3 if necessary):horizontal divider

Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization, or institution?

Yes______ No______

If yes: what is the status of the grievance?

Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?

Yes______ No______
If yes:

Agency or Court:horizontal divider

Contact Person:horizontal divider

Address:horizontal divider

City, State, and Zip Code:horizontal divider

Telephone Number:horizontal divider

Date Filed:horizontal divider

Do you intend to file with another agency or court?

Yes______ No______
Agency or Court:horizontal divider

Address:horizontal divider

City, State and Zip Code:horizontal divider

Telephone Number:horizontal divider

Additional space for answers: horizontal divider horizontal divider horizontal divider horizontal divider horizontal divider horizontal divider

Signature: _________________________________________

Date: ________________________________

To file an ADA complaint by mail, send this completed form to:

U.S. Department of Justice
950 Pennsylvania Avenue, NW
Civil Rights Division
Disability Rights Section
Washington, D.C. 20530

To file an ADA complaint by facsimile, fax this completed form to: (202) 307-1197

Paperwork Reduction Act Statement
This request is in accordance with the Paperwork Reduction Act of 1995, 44 U.S.C. § 3507.  This information collection is for the purpose of allowing the Department of Justice’s Disability Rights Section (DRS) to engage in authorized civil rights compliance and enforcement activities. Providing the information is voluntary, except that failure to provide such information may result in DRS being unable to process your complaint. The estimated average burden associated with this collection is 45 minutes per response, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden may be sent to DRS by email at: DRS.PRA@crt.usdoj.gov.  An 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.

Privacy Act Statement
The Americans with Disabilities Act of 990, 42 U.S.C. §§ 12131-12134, and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794, authorize the solicitation of the information for this form.  Providing the information is voluntary, except that failure to provide such information may result in the Department of Justice’s Disability Rights Section (DRS) being unable to process your complaint. The principal purpose of collecting information from you is for DRS’s authorized civil rights compliance and enforcement activities. DRS will not disclose your name or other identifying information about you unless it is necessary for enforcement activities against an entity alleged to have violated federal law, required to be disclosed under the Freedom of Information Act, 5 U.S.C. § 552, disclosure is permitted pursuant to the Privacy Act, or is otherwise required by law. The records that you provide to DRS may be disclosed in accordance with the provisions of the Privacy Act, including: to appropriate Federal, State, or local agencies; Members of Congress or staff; volunteer student workers within the Department of Justice so that they may perform their duties; the news media and the public pursuant to 28 C.F.R. § 50.2, unless it is determined that release of the specific information in the context of a particular case would constitute an unwarranted invasion of personal privacy; the National Archives and Records Administration and General Services Administration to perform records management inspection functions in accordance with their legal responsibilities, or; for other routine uses indicated in the JUSTICE/CRT-001 “Central Civil Rights Division Index File and Associated Records” system of records notice. To view the routine uses applicable to this system of records, please consult the system of records notice, as amended, at the following links:
68 Fed. Reg. 47610 ,611 at https://www.gpo.gov/fdsys/pkg/FR-2003-08-11/pdf/03-20342.pdf
70 Fed. Reg. 43904 at https://www.gpo.gov/fdsys/pkg/FR-2005-07-29/pdf/05-14944.pdf
82 Fed. Reg. 24147 at https://www.gpo.gov/fdsys/pkg/FR-2017-05-25/pdf/2017-10780.pdf

Last updated May 2019