Appendix C "Americans With Disabilities Act Complaint Form" - New York

What Is Appendix C?

This is a legal form that was released by the New York State Department of Public Service - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the New York State Department of Public Service;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Appendix C by clicking the link below or browse more documents and templates provided by the New York State Department of Public Service.

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Download Appendix C "Americans With Disabilities Act Complaint Form" - New York

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Procedures for Implementing Reasonable
Accommodation in Programs and Services
for Individuals with Disabilities
Procedures for Implementing Reasonable
Accommodation in Programs and Services
for Individuals with Disabilities
Appendix C:
AMERICANS WITH DISABILITIES ACT COMPLAINT
FORM
Please use this form to file a complaint based on disability in the provision of services,
activities, programs or benefits.
Please submit this form to the Department of Public Service ADA Coordinator, Michele
Newkirk. Your complaint can be sent to Ms. Newkirk at: Department of Public Service, 3
Empire State Plaza, Albany, NY 12223. Ms. Newkirk may be reached at (518) 486-2435.
COMPLAINANT INFORMATION
Name:
Home Phone:
Home Address:
Email:
1. Your claim is made against:
State Agency:
Name:
Title:
Address:
Phone:
2. Location(s) and date(s) of the circumstances giving rise to your complaint:
Are the circumstances of your complaint continuing?
Yes
No
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3. Please describe the alleged denial of services, activities, programs or benefits and your
reason(s) for concluding that the conduct was discriminatory. Please include the
name(s) of witnesses, if any, and attach supporting data, if available.
4. A. Have you filed a claim regarding this complaint with a federal, state or local
government agency?
Yes
No
B. Have you hired an attorney with respect to the allegations in the complaint?
Yes
No
C. Have you instituted a legal suit or court action regarding this complaint?
Yes
No
5. This complaint form was completed by:
ADA Coordinator
Complainant
SIGNATURE: ___________________________________
DATE: ____________
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