TITLE 4: DISCRIMINATION PROCEDURES
CHAPTER XXVIII: COMPTROLLER
PART 775 AMERICANS WITH DISABILITIES ACT GRIEVANCE PROCEDURE
SECTION 775.APPENDIX A: GRIEVANCE FORM
Section 775.APPENDIX A: Grievance Form
Discrimination Based on Disability
It is the policy of the Office of the Comptroller to provide assistance in filling out this form. If assistance is needed, please ask:
ADA Coordinator – Office of the Comptroller
325 West Adams Street
Springfield, Illinois 62706
217/782-6000 (Voice) – 217/782-1308 (TTD)
I certify that I am qualified or otherwise eligible to participate in the program, service or activity and the above statements are true to the best of my knowledge and belief.
Please give to the ADA Coordinator at the address listed above.
For Office Use Only
Date Received: ____________________ By: __________________________________