Illinois Administrative Code
Title 4 - DISCRIMINATION PROCEDURES
Part 775 - AMERICANS WITH DISABILITIES ACT GRIEVANCE PROCEDURE
Appendix A - Grievance Form
Grievance
Discrimination Based on Disability
It is the policy of the Office of the Comptroller to provide assistance in filling out this form. If assistance is needed, please ask:
ADA Coordinator - Office of the Comptroller
325 West Adams Street
Springfield, Illinois 62706
217/782-6000 (Voice) - 217/782-1308 (TTD)
Name: ________________________________________________________________
Address: ______________________________________________________________
City, State and Zip Code: __________________________________________________
Telephone No.: __________________________________________________________
The Best Means and Time for Contacting: ______________________________________
Program, Service, or Activity to which Access was Denied or in which Alleged Discrimination Occurred: ____________________________________________________________________
Nature of Alleged Discrimination:
______________________________________________________________________
______________________________________________________________________
(Attach additional sheets, if necessary.)
I certify that I am qualified or otherwise eligible to participate in the program, service or activity and the above statements are true to the best of my knowledge and belief.
| __________________ | __________________ |
|
Signature |
Date |
Please give to the ADA Coordinator at the address listed above.
For Office Use Only
Date Received: ____________________ By: __________________________________
