Action Center / Human Rights ADA Grievance Form / The City of Muncie, Indiana

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PLEASE READ COMPLETELY BEFORE FILLING OUT FORM. THIS COMPLETED PRELIMINARY INFORMATION DOES NOT CONSTITUTE A COMPLAINT.

The Americans with Disabilities Act information packet (which includes a City of Muncie resolution, City responsibilities and procedures, and a form) can be downloaded by visiting the City of Muncie Human Rights webpage.

A formal complaint may be completed at a later date.

THIS INTAKE SURVEY WILL ALLOW US TO DETERMINE IF WE CAN TAKE YOUR COMPLAINT - PLEASE COMPLETE IT TO THE BEST OF YOUR ABILITY. IF YOU NEED ASSISTANCE, CONTACT US.

NOTICE OF CONFIDENTIALITY

The information contained in this communication from the Office of the City of Muncie Human Rights Commission is privileged and confidential, and is intended for the sole use of the person or entities who are the addressees. If you are not an intended recipient of this communication, the dissemination, distribution, copying, or use of the information it contains is strictly prohibited. If you have received this communication in error, please immediately contact the Commission at (765)747-4854 to arrange for the return of this information. Thank you.

* Denotes a required field

Contact Information

Name*

Email Address*

Daytime Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Address*

Individual discriminated against (if different than above)

Address (if different than above)

Complaint Information

Please Do Not Complete The Following Field

Alleged violation date and approximate time*

MonthDay Year, HourMinute : AM/PM

Detailed description of violation*

County department or location involved*

Requested action by County to correct violation*

Has complaint been filed with State or Federal agency?*

Yes

If Yes: name of agency, date, contact person

List of witnesses

Human Rights ADA Grievance Form

Contact Information

Complaint Information

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