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Reasonable Modification Program Complaint Form

Section I:
Contact Information: Lisa Salyers at (812) 876-3383 Ext 622 or lsalyers@area10agency.org
Name*
First Last
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Accessible Format Requirements?
- Large Print
- TDD
- Audio Tape
- Other
If "Other" please describe
Section II:
Are you filling out 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 filling 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 informationof any witnesses. If more space is needed please email additional information/pictures, etc to Lisa Salyers at lsalyers@area10agency.org
Section IV
Have you previously filed a complaint with this agency?
- Yes
- No
By typing name below and submitting that will be considered a signed complaint:
First Last
Agency Contact: Lisa Salyers, Assistant Rural Transit Manager ~ (812) 876-3383 Ext. 622 ~ lsalyers@area10agency.org ~any additional comments below:
Date
MM slash DD slash YYYY
CAPTCHA

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