DEPARTMENT ON DISABILITY

1. fill out (type in the provided fields) hint: you may tab through the form
2. convert to printable form
3. print (remember to sign the form after you print it)
4. mail to:

Department on Disability, Disability Access and Services,
333 South Spring Street
Los Angeles, California 90013

Attention:
Mitch Pomerantz, ADA Compliance Officer,
(213) 847-9124
or
Richard Ray, ADA Compliance Officer (Deaf and Hard-of-Hearing Services Program),
(213) 847-9123 Voice or (213) 847-6560 TTY.

Request may be send via the facsimile at (213) 485-8052.

(Attachment B)

TITLE II, AMERICANS WITH DISABILITIES ACT GRIEVANCE FORM
Instructions: Please fill out this form in black ink or type. Sign and return it.

Grievant:
Address:
City:
State:	Zip Code:
Telephone
Home:
Business:
Person Alleging Violation of Title II
(if other than the grievant):
Address:
City:
State:	Zip Code:
Telephone
Home:
Business:
City Department, Bureau or Service:
Address:
City:
State:	Zip Code:
Telephone
Home:
Business:
When did the alleged violation occur?
Date:
Describe the alleged act(s), providing name(s) where possible of the individuals who allegedly violated Title II. (attach additional pages if necessary.)
Has this complaint been filed with the Department of Justice or any other Federal, State, or local civil rights agency or court?
Yes:	If yes please complete section B
No:
Section B
Agency or Court:
Contact Person:
Address:
City:
State:	Zip Code:
Telephone:
Date Filed:
Additional space for answers:
Signature:_____________________________ Date:________________