Fillable AFFIRMATIVE ACTION AMERICANS WITH DISABILITIES ACT COMPLAINT FORM (New York Department of Motor Vehicles)

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AFFIRMATIVE ACTION AMERICANS WITH DISABILITIES ACT COMPLAINT FORM (New York Department of Motor Vehicles)

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LISA G. DiCOCCO
Affirmative Action Officer
Designee for Reasonable
Accommodation (DRA)
ADA Coordinator
AFFIRMATIVE ACTION
6 EMPIRE STATE PLAZA • ALBANY, NY 12228
AMERICANS WITH DISABILITIES ACT COMPLAINT FORM
Please use this form to file a complaint based on disability in the provision of services, activities, programs, or benefits.
Please submit this form to the ADA Coordinator, Lisa G. DiCocco at the NYS Department of Motor Vehicles; you may
find contact information for Lisa G. DiCocco on form PE-701 at http://dmv.ny.gov/forms/pe701.pdf.
COMPLAINANT INFORMATION
Name: Home Phone:
Home Address:
Email:
1. Your claim is made against:
State Agency:
Name:
Title:
Phone:
Address:
2. Location(s) and date(s) of the circumstances giving rise to your complaint:
Are the circumstances of your complaint continuing?
Yes No
PE-703 (1/17)
PAGE 1 OF 2
3. Please describe the alleged denial of services, activities, programs or benefits and your reason(s) for concluding
that the conduct was discriminatory. Please include the name(s) of witnesses, if any, and attach supporting data,
if available.
4. A. Have you filed a claim regarding this complaint with a federal, state, or local government agency?
Yes No
B.
Have you hired an attorney with respect to the allegations in the complaint?
Yes No
C. Have you instituted a legal suit or court action regarding this complaint?
Yes No
5. This complaint form was completed by:
ADA Coordinator Complainant
SIGNATURE:
DATE:
PE-703 (1/17)
PAGE 2 OF 2
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AFFIRMATIVE ACTION AMERICANS WITH DISABILITIES ACT COMPLAINT FORM (New York Department of Motor Vehicles)

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Completed 12 August 2021

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