Ill. Admin. Code tit. 4, pt. 775, app A
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: __________________________________
Ill. Admin. Code tit. 4, pt. 775, app A