ADA Complaint Form

Any person who believes himself, herself  or  any specific  class of  persons to be  subjected to discrimination  may also file a written complaint with  the  Federal  Transit  Administration  (FTA),  Office of Civil Rights, 1200  New Jersey Avenue SE, Washington, DC 20590.

Note: To protect your rights, your complaint must be filed  with  180  days  of the  occurrence.  Failure  to file within 180 days may result in dismissal of the complaint.


Complainant's Name
Zip Code
Telephone# Home
Telephone# Work
Telephone# Cell
Person Discriminated Against (if someone other than Complainant)
Name of Person Discriminated Against (other than Complainant)
Address of Person Discriminated Against (if someone other than Complainant)
City (if someone other than complainant)
State (if someone other than complainant)
Zip Code (if other than complainant)
Telephone# Home (if other than complainant)
Telephone# Work (if other than complainant)
Telephone# Cell (if other than complainant)
Upon what premise is your discrimination complaint based? (check all that apply)
Date of alleged discrimination or alleged violation (or date range if this took place more than once):
Describe the alleged discrimination or alleged violation. Explain what occurred and who you believe was responsible.
Where did the incident take place? Please provide location, time, bus number etc.
Witnesses? Please provide their contact information.
Name of Witness 1
Address of Witness 1
City of Witness 1
State of Witness 1
Zip Code of Witness 1
Telephone# Cell Witness 1
Telephone# Home Witness 1
Telephone# Work Witness 1
Name of Witness 2
Address of of Witness 2
City of Witness 2
Zip Code of Witness 2
State of Witness 2
Telephone# Home Witness 2
Telephone# Work Witness 2
Telephone# Cell Witness 2
How can this complaint be resolved (how can the problem be corrected)?
Optional Information If applicable, name and title of person(s) who allegedly discriminated against you:
Is this activity still on-going?
Did you file this complaint with another federal, state or local agency, or with a federal or state court? (Check the appropriate space)
If your answers is YES check each agency with which a complaint was filed:
Please provide contact information for the agency you also filed the complaint with:
Date Filed
If you need any special accommodations for communication regarding this complaint, please specify which alternative format you require.
Special Accommodations Clarification (specify font size, specify sign language, specify specific language)
Sign the complaint in space below.
Complainant's Signature
Max. Size: 10000kb Extensions: pdf,doc,docx,jpg,jpeg