ADA or Title VI Complaint - Enrichment Centers for Huron County

Part I. Please check one of the following:

ADA Complaint
Title VI Complaint

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Additional Formats Needed:

None
Large Print
TDD
Audio Tape
Other

Part II. Are you filing this complaint you your own behalf?

Name of Individual

Your Relationship

Please explain why you have filed for a third party:

Confirm:

I have obtained permission of the aggrieved party to file this form on his or her behalf.
I have not confirmed permission to file this form on behalf of the aggrieved party.

Part III. I believe the discrimination I experienced was based on:

Race
Color
National Origin
My Disability
Other

Please explain:

Date of alleged discrimination:

Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.

Part IV. Have you previously filed an ADA and/or Title VI complaint with this agency?

Part V. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

If yes, check all that apply:

Federal Agency
State Agency
Local Agency
Federal Court
State Court

Please provide the contact information for a person at the agency or court where the complaint was filed:

First

Last

Title:

Agency:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Telephone:

Email:

Part VI. Name of agency complaint is against:

Contact person:

Title:

Phone

Important Notice: To protect your rights, your complaint must be filed within 180 days following the date of the alleged discrimination. Failure to file within 180 days may result in dismissal of the complaint. You may attach any additional written materials or other information that you think is relevant to your complaint to this form.

File Upload: max file size is 1MB. Allowed file extensions are .pdf and .doc.

Click or drag files to this area to upload. You can upload up to 3 files.

Signature and date required: *

First

Last

Date: *

NORWALK

130 Shady Lane

M-Th 8:00 - 4:30

F 8:00 - 2:30

Sa -Su CLOSED

WILLARD

315 East Tiffin Street

M-Th 8:00 - 3:30

F 8:00 - 2:30

Sa -Su CLOSED

NORWALK

WILLARD