Compliance Complaint Form (Click Here)

Section I:

Contact Information: Lisa Salyers at 812-876-3383 Ext 622 or lsalyers@area10agency.org

Name

First Last

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

Reasonable Modification Program Complaint Form

Section I:

Section II:

Section III:

Section IV

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