Ill. Admin. Code tit. 80 , 1540.415 app A
Grievance
Discrimination Based on Disability
It is the policy of the State Employees' Retirement System to provide assistance in filling out this form. If assistance is needed, please ask:
State Employees' Retirement System, ADA Coordinator
2101 S. Veterans Parkway, P. O. Box 19255
Springfield IL 62704
217-785-7444, 217-785-7218 (TDD)
Name: _______________________________________________________________
Address: _____________________________________________________________
City, State and Zip Code: _________________________________________________
Telephone No.: _________________________________________________________
Program, Service or Activity to which Access was Denied or in which Alleged Discrimination Occurred: ___________________________________________________________________
Date of Alleged Discrimination: _____________________________________________
Nature of Alleged Discrimination: ____________________________________________
(Attach additional sheets, if necessary, and copies of any documents received or submitted to the System that pertain to the program, activity or service referred to in this grievance. If the grievance is based on a denial of requested reasonable modification, please fill out the back of this form.)
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.
Ill. Admin. Code tit. 80 , 1540.415 app A