Ill. Admin. Code tit. 4, § 775.APPENDIX – 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: __________________________________