Reasonable Modification/Accommodation Complaint Form Name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Accessible Format Requirements?Large PrintTDDAudio TypeAre you filing this complaint on your own behalf?*YesNoPlease supply the name of the person for whom you are complaining.* First Last Please state the relationship between you and the person for whom you are complaining.*Please explain why you have filed for a third party.Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of that party.*YesNoThird ChoiceDiscriminatory IncidentWhat date did the refusal occur?* Date Format: MM slash DD slash YYYY Primary type of disability?*Please check specific disabilityMobilityCognitive/Intellectual/DevelopmentLearningMental/PsychiatricVisionHearingSeizureSpeechHIV/AIDSDiabetesSpecific Issue:*Physical AccessInterpreter/Assisted LivingService AnimalRetaliationDenial of ServiceNot Sure/Do Not KnowDescribe the refusal of the reasonable accommodation:*
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