State of Michigan ADA Appeal Form

Do you believe you have been subjected to discrimination by a state government entity based on disability? Are you unable to access a state program, service, or activity due to your disability? Use this form to report disability discrimination to the State of Michigan’s ADA Coordinators.

If you wish to report your concerns of discrimination in another format, you may do so by contacting the state government entity’s ADA Coordinator directly using the ADA Coordinator contact list.

More information on this complaint process can be found on the ADA Complaint Procedure webpage.

Caution: Please remember to save and/or print your completed appeal form before using the Submit button.

Note: When you use the Submit button the information is transmitted electronically to the State of Michigan department or agency selected, and at the same time the information is cleared from the form.

Please use your browser's 'Save as' functionality to save a copy of your completed form for your records.

Please use your browser's 'Print' functionality to print a copy of your completed form for your records and/or to mail your appeal if you wish to submit the appeal using the United States Postal Service.

All fields are required unless labeled optional.

Last Name First Name Middle Name (optional) Address Line 1 Address Line 2 (optional) City State ZIP Code Phone Number (preferred) Email Address Is this your first submittal of an appeal? Yes No If No, where the appeal was filed and whether it was filed with a Federal, State, or Local Civil Rights Agency or Court. (optional) Describe what the proposed Department or Agency resolution is and why it is not a satisfactory resolution to the discriminatory incident. Date of discriminatory incident Which State of Michigan Department or Agency was involved Complaint Issue If Other is selected please describe what the type of complaint is List your primary ADA qualified disability

Available Forms

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State of Michigan ADA Appeal Form