Skip to content

Main Office: (812) 876-3383

Toll-free: (800) 844-1010

631 West Edgewood Drive, Ellettsville, IN 47429

Facebook Twitter Pinterest LinkedIn

Search for:

Home
About Us
Services
News
- Quarterly Newsletter
Events
- Calendar
- Signature Events
Show Your Support
Join The Team
Locations
Contact

Resources.
Solutions.
Connections.

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

Show Your Support!

Help us continue providing health & wellness services to the community!
Donate

Want to Volunteer?

There are many opportunities available, including volunteering as a patriot pal, joining the RSVP 55+ Volunteer Program or helping out at the Endwright Center!
Volunteer

Need Help?

For more information about our programs and services, call our Aging and Disability Resource center today
(800) 844-1010

Thanks to the continued support of our community partners!

Newsletter Signup

Stay Connected!

631 West Edgewood Drive
Ellettsville, IN 47429

Main Office:

Toll-free:

Fax:

Resources

For Seniors
For Caregivers
For Persons with Disabilities
For Supporters

United Way Member

Sage Care 2022 Bronze

Solutions

Information & Referral
In-Home Services
Health & Wellness
Transportation & Housing
Need Help with services? Complete this online form and an Area 10 staff person will contact you soon!

Connections

Volunteer Opportunities
Work With Us
Upcoming Events
Contact Us

Copyright © 2024 Area 10 Agency on Aging. All Rights Reserved. | Site by Monster Digital Marketing, a Bloomington Web Design Co.