S T A T E   O F   C A L I F O R N I A 
D E P A R T M E N T   O F   G E N E R A L   S E R V I C E S 

AMERICANS WITH DISABILITIES ACT (ADA) GRIEVANCE FORM 

INSTRUCTIONS:  This is a printable form.  
Simply complete, print, and send to:  
Department of General Services
Att’n:  ADA Coordinator
P.O. Box 989052
West Sacramento, CA  95798-9052 

I. COMPLAINANT INFORMATION 

Name: 
Street Address: 
City: 
State: 
Zip Code 
Home Phone (include area code): 
Business Phone (include area code): 

II. PERSON ALLEGING ADA VIOLATION (if other than complainant) 

Name:
Street Address:
City: 
State: 
Zip Code:
Home Phone (include area code): 
Business Phone (include area code): 

III. INFORMATION ON ALLEGED VIOLATION 

Date alleged violation occurred: 
Description of alleged violation:



Requested remedy: 




Has this complaint been filed with the responsible Federal enforcement 
agency, U.S. Department of Justice, or Court?  (Y/N):

IV. COMPLETE THE FOLLOWING IF YOU ANSWERED “YES” TO 
THE PREVIOUS QUESTION 

Agency or Court: 
Contact Person:
Street Address: 
City: 
State:
Zip Code: 
Phone (include area code): 
Date Filed: 

Other Comments: 




Signature: 
Date :