Complaint Form

Americans with Disabilities Act Complaint Form

UCP of Hudson County is committed to ensuring that no person is denied access to its services, programs, or activities on the basis of their disabilities, as provided by title II of the Americans with Disabilities Act of 1990 (“ADA”). ADA complaints must be filed within 180 days from the date of the alleged incident.

The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, or if you would like to make a verbal complaint, please contact the Keith J Kearney at 291-436-2200 or at 721 Broadway, Bayonne, NJ 07002.

Complainant:

Phone:

Street Address:

City, State, Zip Code

 Alt Phone:

Person Preparing Complaint (if different from Complainant):

Street Address, City, State, Zip Code

Date of Incident: _________________________

Please describe the alleged discriminatory incident, including the location(s), if applicable. Provide the names and titles of UCP of Hudson County employees involved, if available.

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Description of incident continued:

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Have you filed a complaint with any other federal, state, or local agencies? Yes/No (Circle One).

If so, list agency/agencies and contact information below:

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Agency Contact Name:

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Street Address, City, State, Zip Code Phone:

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Agency Contact Name:  ______________________________________________________________________________

I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief.

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Complainant’s Signature                                               Date

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Print or Type Name of Complainant

Date Received: ______________________

Received By: ________________________