Revised 4.19.19
COMMONWEALTH OF MASSACHUSETTS
JUDICIARY
ADA COMPLAINT FORM
The information provided below will assist the Court in investigating and, if possible, resolving complaints pertaining
to discrimination on the basis of disability. Please send the completed form to the ADA Coordinator for the court
against whom the claim of discrimination is being made (see contact information below). If you are unsure of which
court to direct your complaint to, send it to either of the ADA Coordinators identified below and he or she will forward
it to the appropriate court.
A. Your Name and Contact Information
1.
Complainant's Full Name
2.
Complainant's Complete Address
3.
Complainant's Day Phone
4.
Complainant's Alternate Phone
5.
Complainant's Email address
6.
Best time to contact complainant
7.
Best way to contact complainant
B. Complaint Information
1.
Incident date:
2.
Incident time:
3.
Place of Incident (please be specific, e.g., conference room, entrance)
4.
Please provide specific details about this incident and your complaint. Please
attach extra pages if necessary.
C. Is Complaint Related to a Case? If so, please provide case name, docket number, and
court in which the case was or is being heard.
D. Names and Contact Information of Witnesses
By signing this document, I acknowledge that, to the best of my knowledge and belief, the statements made
in this complaint are true.
Complainant's signature:
Date:
This document may be available in an alternate format. Please contact the ADA Coordinator.
click to sign
signature
click to edit
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