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Beaufort County
ADA/Section 504 Grievance Form
Beaufort County prohibits discrimination against qualified individuals with
disabilities in its services, programs, or activities, including federally
assisted services, programs, or activities.
Sufficient data should be included to substantiate any claims or charges.
Additional supporting documentation may be attached to this form.
Grievant Name:
Address:
City, State, Zip:
Daytime Phone: Evening Phone:
Other Contact Information
Who else may we call if we cannot reach you?
Daytime Phone: Evening Phone:
Name, address and telephone number of the person who was allegedly discriminated against, if
different from the person filing the complaint.
1. Please describe the alleged act of discrimination that caused you to file this
complaint?
2. What date (mm/dd/yyyy) and time did the incident occur?
