Skip to content
NORWALK: 419.668.6245
|
WILLARD: 419.933.4701
Donate Today
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
Home
News
Events
Services
Age Exchange
Facility Rental
HEAP
Information and Referral
Medicare Part D Assistance
Project Lifesaver
Transportation
Huron County Transit
Senior Express
Travel
Meals
Meal Options
Menu Calendar
Volunteer
Donate
Contact
Contact Us
Careers
Links
ADA or Title VI Complaint
ADA or Title VI Complaint
Jen Test
2022-09-22T16:23:52-04:00
Please enable JavaScript in your browser to complete this form.
–
Step
1
of 6
Part I. Please check one of the following:
ADA Complaint
Title VI Complaint
Name
First
Last
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Email
Additional Formats Needed:
None
Large Print
TDD
Audio Tape
Other
Next
Part II. Are you filing this complaint you your own behalf?
Yes
No
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.
Previous
Next
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.
Previous
Next
Part IV. Have you previously filed an ADA and/or Title VI complaint with this agency?
Yes
No
Previous
Next
Part V. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?
Yes
No
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Telephone:
Email:
Previous
Next
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:
*
Submit
Page load link
Go to Top