10/29/2024
Complaint Form
Franklin County Services for the Elderly Title VI / ADA / Complementary Paratransit Complaint Form
The purpose of this form is to assist you in filing a complaint with Franklin County Services for the Elderly. You are not required to use this form; a letter containing the same information will be sufficient.
For questions about Franklin County Services for the Elderly’s Americans with Disabilities Act (ADA) complaint procedures or complaint form contact RaJeanna Barnhard at 785-242-7440 or [email protected]
Section I:
Name:
Address:
Telephone (Home): Telephone (Work):
Electronic Mail Address:
Accessible Format
Requirements? Large Print Audio Tape
TDD Other
Section II:
Are you filing this complaint on your own behalf? Yes* No
*If you answered "yes" to this question, go to Section III.
If not, please supply the name and relationship of the person
for whom you are complaining:
Please explain why you have filed for a third party:
Please confirm that you have obtained the permission of the
aggrieved party if you are filing on behalf of a third party. Yes No
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Section III:
I believe the discrimination I experienced was based on (check all that apply):
☐ Race ☐ Color ☐ National Origin ☐ Age
☐ Disability ☐ Accessibility Issue ☐ Other (specify) ______________________
Date of Alleged Discrimination (Month, Day, Year):
Time of Day:
Location:
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please attach additional pages.
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Witness(es): ☐ YES ☐ NO
List Witness(es): (Attach a separate sheet, if necessary)
(1) Name:
Phone Number: ( )
(2) Name:
Phone Number: ( )
(3) Name:
Phone Number: ( )
(4) Name:
Phone Number: ( )
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Section IV
Have you previously filed an ☐ ADA or ☐ Title VI complaint with this
agency? Yes No
Section V
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 information about a contact person at the agency/court where the complaint was
filed.
Name:
Title:
Agency:
Address:
Telephone:
Section VI
Name of agency complaint is against:
Contact person:
Title:
Telephone number:
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You may attach any written materials or other information that you think is relevant to your complaint.
Signature and date required below:
Signature _______________________________________ Date________________________
Please submit this form in person at the address below, or mail this form to:
ADA Coordinator
Franklin County Services for the Elderly
114 W 2nd
Ottawa, KS 66067
Send a message to learn more
