Form FTB5722 "Grievance Form" - California

What Is Form FTB5722?

This is a legal form that was released by the California Franchise Tax Board - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the California Franchise Tax Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form FTB5722 by clicking the link below or browse more documents and templates provided by the California Franchise Tax Board.

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Download Form FTB5722 "Grievance Form" - California

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Americans With Disabilities Act (ADA) Title II
Grievance Form
Purpose: Use this form to file a grievance if you find that the Franchise Tax Board has not provided adequate
accommodation for a disability.
Instructions: Complete this form, print it, sign it and mail to:
FRANCHISE TAX BOARD
EQUAL EMPLOYMENT OPPORTUNITY OFFICE MS A163
PO BOX 550
SACRAMENTO CA 95812-0550
Grievant Information
Grievant Name
Address
City
State
ZIP Code
Home Phone (include area code)
Business Phone (include area code)
(
)
(
)
Person (other than Grievant) Alleging an ADA Violation
Name
Address
City
State
ZIP Code
Home Phone (include area code)
Business Phone (include area code)
(
)
(
)
FTB Service, Program or Facility Allegedly in Violation
Date Alleged Violation Occurred (dd/mm/yyyy)
Description Of Alleged Violation and Requested Remedy
Has this case been filed with the Department of Justice or other government agency or court?
Yes
No
FTB 5722 (REV 02-2018) SIDE 1
Americans With Disabilities Act (ADA) Title II
Grievance Form
Purpose: Use this form to file a grievance if you find that the Franchise Tax Board has not provided adequate
accommodation for a disability.
Instructions: Complete this form, print it, sign it and mail to:
FRANCHISE TAX BOARD
EQUAL EMPLOYMENT OPPORTUNITY OFFICE MS A163
PO BOX 550
SACRAMENTO CA 95812-0550
Grievant Information
Grievant Name
Address
City
State
ZIP Code
Home Phone (include area code)
Business Phone (include area code)
(
)
(
)
Person (other than Grievant) Alleging an ADA Violation
Name
Address
City
State
ZIP Code
Home Phone (include area code)
Business Phone (include area code)
(
)
(
)
FTB Service, Program or Facility Allegedly in Violation
Date Alleged Violation Occurred (dd/mm/yyyy)
Description Of Alleged Violation and Requested Remedy
Has this case been filed with the Department of Justice or other government agency or court?
Yes
No
FTB 5722 (REV 02-2018) SIDE 1
If You Answered “Yes” to the Previous Question, Complete the Following
Agency or Court
Contact Person
Address
City
State
ZIP Code
Phone (include area code)
Date Filed (dd/mm/yyyy)
(
)
Other Comments
Signature
Date:
FTB 5722 (REV 02-2018) SIDE 2
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