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
Section III: Date that Reasonable Modification was Denied (Month, Day, Year): _____________________________ Explain as clearly as possible what happened and why you believe you should have received the modification request. Describe all persons who were involved. Include the name and contact information of the person(s) (if known) as well as names and contact information of any witnesses. If more space is needed, please use the back of this form. You may also attach other items that you think are relevant. _____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________ Section IV Have you previously filed a complaint with this agency? ____Yes ____No
Signature and date required. Please submit the form in person or via mail/email.
_____________________________________________________________________________________ Signature Date
Access Johnson County Public Transit Attn: Jennifer Moss, Compliance Officer PO Box 216, Franklin, IN 46131 jennifer.moss@gatewayarc.com