Attachment A

ADA Complaint Form

Title II of the Americans with Disabilities Act COMPLAINT FORM

Instructions: Please fill out this form completely, in black ink or type. Sign and return to the address on page 4.

Complainant

Address

City, State and Zip Code

Telephone: Home

Telephone: Business

Person Making the Complaint (if other than the complainant)

Name

Address

City, State, and Zip Code

Telephone: Home

Telephone: Business

Department/Agency which you believe has discriminated

Name

Address

County

City

Page 1 of 5

Telephone Number

When did the event occur? Date

Describe the event providing the name(s) where possible for the individuals who were involved (use the additional space on page 3 if necessary)

Has the complaint been filed with the Ohio Department of Civil Rights or the Federal Department of Justice or any other Federal agency or court?

Yes No

If yes

Agency or Court

Contact Person

Address

City, State, and Zip Code

Telephone Number

Date Filed

Page 2 of 5

Do you intend to file with another agency or court?

Yes No

Agency or Court

Address

Telephone Number

Additional space for answers

Signature

Page 3 of 5

Date

Return to

Cheryl Boley
5250 State Route 37 East
PO Box 311
740-342-3555
Cheryl.Boley@jfs.ohio.gov

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Regulations

49 CFR Parts 27, 37 and 38

http://www.fta.dot.gov/12876_3906.html (opens in a new tab on fta.dot.gov, a third-party website outside perrycountytransit.com)

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