Title VI and ADA Complaint Form

Independent Living Center of the Hudson Valley, Inc.

Title VI and ADA Complaint Form

Section I:
Your Name:
Address:
Telephone (Home):		Telephone (Work/Mobile):
Email Address:
Accessible Format Requirements?	Large Print		Audio Tape
	TDD		Other
Section II:
Are you filing this complaint on your own behalf?				Yes*	No
*If you answered “yes” to this question, go to Section III.
If not, please supply the name and relationship of the person for whom you are complaining:
Please explain why you have filed for a third party:

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.				Yes		No
Section III:
I believe the discrimination I experienced was based on (check all that apply): ☐ Race ☐ Color ☐ National Origin ☐ Disability Date of Alleged Discrimination (Month, Day, Year): _____________ Independent Living Center of the Hudson Valley complaint is against: ______________________________________________ Location of where the alleged discrimination occurred:- _____________________________________ Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please attach additional pages. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Section IV

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

☐ Yes ☐ No

If yes, check all that apply:

☐ Federal Agency:

☐ Federal Court: ☐ State Agency:

☐ State Court: ☐ Local Agency:

Provide information for the contact person at the agency/court where the complaint was filed.

Name and Title:

Agency:

Address:

Telephone:

You may attach any written materials or other information that you think is relevant to your complaint.

Signature and date required below.

_____________________________________ ________________________

Signature Date

Please submit this form by mail, email or in person to the address below.

Independent Living Center of the Hudson Valley, Inc.
Simeon Goldman, Esq.

Title VI/ADA Coordinator

15-17 Third St

Troy, NY 12180

sgoldman@ilchv.org

This complaint may also be filed directly with the New York State Department of Transportation, Office of Civil Rights, 50 Wolf Road, 6th Floor, Albany, NY 12232, (518) 457-1129 Fax (518) 549-1273, OCR-TitleVI@dot.ny.gov or the Federal Transit Administration, Office of Civil Rights, Attention: Title VI Program Coordinator, East Building, 5th Floor-TCR, 1200 New Jersey Ave., SE Washington, DC, 20590.