ADA 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 Keith J Kearney at 291-436-2200 or 721 Broadway, Bayonne, NJ 07002. 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 based on 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 process your complaint. If you require any assistance in completing this form or would like to make a verbal complaint, please contact Keith J Kearney at 291-436-2200 or 721 Broadway, Bayonne, NJ 07002. A. Complainant’s Information Name * Address Line 1 * City * State * —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code * Phone * Email B. Person Preparing Complaint (If someone other than complainant) Name Address Line 1 City State —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code Phone Email Relationship to the person for whom you are complaining Please explain why you are filing for a third party Do you have permission from the aggrieved party? YesNo D. Date of the Incident Date of Incident * E. Description of the Alleged Discriminatory Incident Please describe the incident, including location(s) and names/titles of UCP of Hudson County employees involved (if available) * F. Have you filed this complaint with any other agency or court? Federal AgencyFederal CourtState AgencyState CourtLocal Agency List details (agency/court names, dates, case numbers) G. AffirmationI AFFIRM THAT I HAVE READ THE ABOVE CHARGE AND THAT IT IS TRUE TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF. Type your full name as a signature * Date * Time * File Upload I affirm the information provided is true to the best of my knowledge and consent to its use for processing this ADA complaint.
