"Americans With Disabilities Act Complaint Form" - New York

Americans With Disabilities Act Complaint Form is a legal document that was released by the New York State Department of Public Service - a government authority operating within New York.

Form Details:

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

Download a printable version of the form 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 "Americans With Disabilities Act Complaint Form" - New York

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NEW YORK STATE
DEPARTMENT OF PUBLIC SERVICE
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, Ms.
Michele Newkirk; at dps.sm.accessibility@dps.ny.gov.
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:
NEW YORK STATE
DEPARTMENT OF PUBLIC SERVICE
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, Ms.
Michele Newkirk; at dps.sm.accessibility@dps.ny.gov.
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 ____
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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