A Grievance Form

Section 775 Section 775.APPENDIX A:  Grievance Form Grievance Discrimination Based on Disability It is the policy of the Office of the Comptroller to provide assistance in filling out this form.  If assistance is needed, please ask: ADA Coordinator – Office of the Comptroller 325 West Adams Street Springfield, Illinois 62706 217/782-6000 (Voice) – 217/782-1308 (TTD) Name: Address: City, State and Zip Code: Telephone No.: The Best Means and Time for Contacting: Program, Service, or Activity to which Access was Denied or in which Alleged Discrimination Occurred: Nature of Alleged Discrimination: (Attach additional sheets, if necessary.) I certify that I am qualified or otherwise eligible to participate in the program, service or activity and the above statements are true to the best of my knowledge and belief. Signature Date Please give to the ADA Coordinator at the address listed above. For Office Use Only Date Received:  ____________________ By: __________________________________