State of Michigan ADA Appeal Form

If you have filed a complaint of disability discrimination and the response to your complaint did not satisfactorily resolve the issue, you can use the form on this page to submit an appeal. The appeal must be submitted within 30 calendar days after receipt of the response.

If you wish to submit your appeal in a different format, please contact the State of Michigan Title II ADA appeals coordinator.

Please see the ADA complaint procedure page for full information about the process.

Print before submitting

Upon selecting the "Submit" button, the information from this form is transmitted electronically to the State of Michigan department or agency selected and the information is also cleared from the form.

Please use your browser's print functionality to print a copy of your completed form for your records, and to mail your appeal if you wish to submit the appeal using the United States Postal Service. The form must be printed BEFORE you select the Submit button.

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