U.S. Department of Justice
   Civil Rights Division
   Disability Rights Section



        Form DOJ - ADA-II OMB Approval No. 1190-0007 (exp. 8-31-95)

              Title II of the Americans with Disabilities Act
               Section 504 of the Rehabilitation Act of 1973
                       Discrimination Complaint Form

   Instructions: Please fill out this form completely, in black ink or
   type. Sign and return to the address on page 3.
   Complainant:
     _________________________________________________________________

   Address:
     _________________________________________________________________

   City, State and Zip Code:
     _________________________________________________________________

   Telephone: Home:

     Business:

   Person Discriminated Against:
   (if other than the complainant)
     _________________________________________________________________

   Address:
     _________________________________________________________________

   City, State, and Zip Code:
     _________________________________________________________________

   Telephone: Home:

     Business:

   Government, or organization, or institution which you believe has
   discriminated:
   Name:
     _________________________________________________________________

   Address:
     _________________________________________________________________

   County:
     _________________________________________________________________

   City:
     _________________________________________________________________

   State and Zip Code:
     _________________________________________________________________

   Telephone Number:
     _________________________________________________________________

   When did the discrimination occur? Date:
     _________________________________________________________________

   Describe the acts of discrimination providing the name(s) where
   possible fo the individuals who discriminated (use space on page 3 if
   necessary):
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________

   Have efforts been made to resolve this complaint through the internal
   grievance procedure of the government, organization, or institution?
   Yes______ No______
   If yes: what is the status of the grievance?
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________

   Has the complaint been filed with another bureau of the Department of
   Justice or any other Federal, State, or local civil rights agency or
   court?
   Yes______ No______
   If yes:
   Agency or Court:
     _________________________________________________________________

   Contact Person:
     _________________________________________________________________

   Address:
     _________________________________________________________________

   City, State, and Zip Code:
     _________________________________________________________________

   Telephone Number:
     _________________________________________________________________

   Date Filed:
     _________________________________________________________________

   Do you intend to file with another agency or court?

     Yes______ No______

   Agency or Court:
     _________________________________________________________________

   Address:
     _________________________________________________________________

   City, State and Zip Code:
     _________________________________________________________________

   Telephone Number:
     _________________________________________________________________

   Additional space for answers:
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________
     _________________________________________________________________

   Signature: _________________________________________
   Date: ________________________________

   Return to:

   U.S. Department of Justice
   Civil Rights Division
   Disability Rights Section
   P.O. Box 66738
   Washington, D.C. 20035-6738