NEW JERSEY JUDICIARY
AMERICANS WITH DISABILITIES ACT GRIEVANCE FORM

Name of Complainant:








Address:









Telephone Number:









Nature of Disability:









Name, Address, and Telephone Number of Alternate Contact Person:









Agency Alleged to Have Denied Access:









Court/Division/Unit:









Location:









Incident or Barrier:









Please describe the particular way in which you  believe you have been denied the benefit of any
service, program, or activity of the Judiciary, or have otherwise been subject to discrimination
as a person with disability by the Judiciary.












Please specify dates, times or incidents, and names or positions of Judiciary employees involved, if any, as
well as names, addresses,and telephone numbers of any witnesses to any such incident. Attach additional pages
if necessary.














This form should be mailed to the ADA Coordinator in the county where the complaint
originated. If you need assistance in completing this form, the ADA Coordinator will help you.