Free ADA Complaint Form.indd - New Jersey

Print Form

Clear Form

New Jersey Judiciary

AMERICANS WITH DISABILITIES ACT COMPLAINT FORM
COMPLAINANT INFORMATION
LAST NAME FIRST NAME MIDDLE NAME

ADDRESS PHONE NUMBER

CITY

STATE DATE

ZIP

Home:

(

)

-

Work (optional):

(

)

-

ALTERNATE CONTACT
LAST NAME FIRST NAME MIDDLE NAME

ADDRESS PHONE NUMBER

CITY

STATE

ZIP

Home:

(

)

-

Work (optional):

(

)

-

COMPLAINT INFORMATION
AGENCY ALLEGED TO HAVE DISCRIMINATED / DENIED ACCESS Supreme Court Superior Court COURT / DIVISION / UNIT LOCATION (City / County) INCIDENT OR BARRIER PLEASE DESCRIBE THE PARTICULAR WAY IN WHICH YOU BELIEVE YOU HAVE BEEN DENIED ANY SERVICE, PROGRAM, OR ACTIVITY OF THE JUDICIARY, OR HAVE OTHERWISE BEEN DISCRIMINATED AGAINST BECAUSE OF, OR RELATED TO, A DISABILITY. PLEASE SPECIFY DATES, TIMES OF INCIDENTS, AND NAMES OR POSITIONS OF JUDICIARY EMPLOYEES INVOLVED. PLEASE PROVIDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ANY WITNESSES. PLEASE ATTACH ADDITIONAL PAGES IF NECESSARY. DATE OF INCIDENT Appellate Division Tax Court Municipal Court

Other ______________________________________________________

IF YOU NEED HELP IN COMPLETING THIS FORM CONTACT THE LOCAL JUDICIARY ADA COORDINATOR. PLEASE RETURN THIS FORM TO THE LOCAL ADA COORINATOR OR TO:

CN: 10975 - English

ADAGREV1.PM6