ADA Transportation Complaint Form

The Americans with Disabilities Act (ADA) prohibits discrimination based on condition or disability. The requested information will assist us in processing your complaint.

Your name(Required)

First Last

Your address(Required)

Street Address Address Line 2 City State ZIP Code

Your phone(Required)

Your email address(Required)

Email Address Confirm Email Address

Person discriminated against (if someone other than the complainant)

First Last

Person discriminated against's address

Street Address Address Line 2 City State ZIP Code

What date did the alleged discrimination take place?

In your words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.(Required)

Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?(Required)

Yes

If yes, check each box that applies:

Federal Agency

Federal Court

State Agency

State Court

Local Agency

Please provide information about a contact person at the agency/court where the complaint was filed.

Street Address Address Line 2 City State ZIP Code

Area Agency on Aging

VCAAA

Advisory Council

Advocacy

Resource Guide

Programs and Services

Resources

Media & Info

ADA Transportation Complaint Form

ADA Transportation Complaint Form

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