Form Center

2. Complainant
3. Phone Number
5. Address
7. City
8. State
9. Zip Code
11. Person Preparing Complaint (If Different from Complainant)
12. Date of Incident
    Date of Incident
14. Address
16. City
17. State
18. Zip Code
20. Describe the alleged discriminatory incident, including the location(s), if applicable. Provide the names and titles of Jefferson Township Dial-A-Ride employees involved, if available:
22. Have you filed a complaint with any other federal, state or local agencies?

    1. Yes
    2. No
24. Agency Name
25. Phone Number
27. Address
29. City
30. State
31. Zip Code
33. I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief:
35. Complainant's Signature
36. Date
    Date
38. Received By:
39. Date Received:
    Date Received:
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field