ADA Complaint Form

If you need this complaint form/information provided in an accessible format, please indicate below:

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Section 1

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Section 2

Are you filling this form out on your own behalf?

Yes
No

If yes, go to Section III

Please provide the name and relationship of the person for whom you are complaining:

Explain why you are filing for this person:

Have you obtained permission from this person?

Yes
No

Date of Alleged Violation

Explain in detail what happened and why you believe there was an ADA violation.

Section 3

Have you previously filed an ADA complaint with the agency?

Yes
No

Section 4

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
Federal Court
State Agency
State Court
Local Agency

Please provide the contact information for a person at the agency where the complaint was filed.

Please provide the persons Name, Business Title, Agency, and Telephone Number

E-Signature

Please type your name to let stand for E-Signature

Date

JATA operates without regard to race, color, or national origin. If you need assistance completing this form, contact JATA at 517-780-3780 or email chad.cumberworth@jacksontransit.com.

Please submit this form in person at the address below, or mail to:

Jackson Area Transportation Authority
Attn: Title VI Coordinator
2350 East High Street
Jackson, MI 49203

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