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 *

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email

__________________________________________________________________

B. Person PREPARING COMPLAINT (if someone other than complainant):

Name

First

Last

Address

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Email

Relationship to 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 aggravated party if you are filing on behalf of a third party.YesNo

__________________________________________________________________

D. DATE OF THE INCIDENT

Date 1 *

__________________________________________________________________

E. Please describe the alleged discriminatORY INCIDENT, INCLUDING THE LOCATION(S), IF APPLICABLE. PROVIDE NAMES AND TITLES OF THE UCP OF HUDSON COUNTY EMPLOYES INVOLVED, IF AVAILABLE

__________________________________________________________________

F. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? List all that apply.

F. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? List all that apply.

• Federal Agency
• Federal Court
• State Agency
• State Court
• Local Agency

If __________________________________________________________________ __________________________________________________________________

If you have checked above, please provide information about a contact person at the agency/court where the complaint was filed.

Name

First

Last

Address

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Email

__________________________________________________________________

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

Signature *

Date / Time *

Date

Time

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