Ill. Admin. Code tit. 4 , 775 app A - Grievance Form

Grievance

Discrimination Based on Disability

It is the policy of the Office of the Comptroller to provide assistance in filling out this form. If assistance is needed, please ask:

ADA Coordinator - Office of the Comptroller

325 West Adams Street

Springfield, Illinois 62706

217/782-6000 (Voice) - 217/782-1308 (TTD)

Name: ________________________________________________________________

Address: ______________________________________________________________

City, State and Zip Code: __________________________________________________

Telephone No.: __________________________________________________________

The Best Means and Time for Contacting: ______________________________________

Program, Service, or Activity to which Access was Denied or in which Alleged Discrimination Occurred: ____________________________________________________________________

Nature of Alleged Discrimination:

______________________________________________________________________

______________________________________________________________________

(Attach additional sheets, if necessary.)

I certify that I am qualified or otherwise eligible to participate in the program, service or activity and the above statements are true to the best of my knowledge and belief.

__________________	__________________
Signature	Date

Please give to the ADA Coordinator at the address listed above.

For Office Use Only

Date Received: ____________________ By: __________________________________

Notes

Ill. Admin. Code tit. 4 , 775 app A