About RCTA

ADA Complaint Form

Redwood Coast Transit is committed to ensuring that no person is denied access to its services, programs, or activities on the basis of their disabilities, as provided by title II of the Americans with Disabilities Act of 1990 (“ADA”). ADA complaints must be filed within 180 days from the date of the alleged incident. Note: The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please let us know.

Name(Required)

First Last

Email(Required)

Address

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

Phone (Main)(Required)

Phone (Alt Phone)

Person discriminated against (if someone other than the complainant)

First Last

Address

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

Person preparing complaint (if different from complainant)

First Last

What date did the alleged incident take place?(Required)

What time did the alleged incident take place?

In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible. Please use the back of this form if additional space is required.(Required)

Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?(Required)

If yes, check all that apply:

Federal Agency

Federal Court

State Agency

State Court

Local Agency

Please provide information about a contact person at the agency/court where the complaint was filed (if available).

First Last

Address

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

Phone

Electronic Signature

Electronic Signature(Required)

Please type your First and Last Name

Date

I understand that checking this box constitutes a legal signature confirming that I acknowledge the truthfulness of the information provided.(Required)

I agree.

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About RCTA

ADA Complaint Form

Electronic Signature

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When:

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