ADA Complaint Form (PDF)

Town of Waterford 
Title II of the Americans with Disabilities Act 
Discrimination Complaint Form 
Instructions: Please fill out this form completely in ink or type it, sign it, and return it to the 
address listed below.  If you need to submit this information in an alternate format, please 
contact the ADA coordinator listed below.   
Lisa L. Cappuccio, ADA Coordinator 
15 Rope Ferry Road 
Waterford, CT 06385 
 
Complainant Contact Information:  
 
Name: 
 
Address:
 
City, State and Zip 
Code:
 
Telephone Numbers with area code:  
Home:   
 
 
 
Business: 
 
 
 
Cell Phone: 
 
 
 
Person Discriminated Against (if other than the 
complainant):
 
Address:
 
City, State, and Zip 
Code:
 
Telephone Numbers with area code:  
Home:   
 
 
 
Business: 
 
 
 
Cell Phone: 
 
 
 
Government, or organization, or institution which you believe has discriminated: 
 
Name:
 
Address:  
 
 City 
 
 
 
 
 
 State  
 
 
 
 Zip Code 
 
Telephone Number with area code: 
 
 
ADA 
Complaint 
Form 

 
 
When did the discrimination occur?  
 
Date:
 
 
Describe the acts of discrimination providing the name(s) where possible of the individuals who 
discriminated (use space on page 3 if necessary): 
 
 
 
 
 
 
 
Have efforts been made to resolve this complaint through the internal grievance procedure of 
the government, organization, or institution? 
 
Yes______ No______ 
 
If yes: what is the status of the grievance? 
 
 
 
 
Has the complaint been filed with another bureau of the Department of Justice or any other 
Federal, State, or local civil rights agency or court? 
 
Yes______ No______ 
 
If yes: 
 
Agency or 
Court:
 
Contact 
Person:
 
Address:
 
City, State, and Zip 
Code:
 
Telephone 
Number:

Date 
Filed:
 
Do you intend to file with another agency or court? 
Yes______ No______ 
 
Agency or 
Court:
 
Address:
 
City, State and Zip 
Code:
 
Telephone 
Number:
 
 
Additional space for answers: 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signature: _________________________________________ 
 
Date: ________________________________ 
 
 
 
 
 
 
 
S:\Senior Services\ADA Compliance\ADA Digital Binder\05-Town of Waterford ADA Complaint Form.doc 5/31/2012