BOE-351 (S1) (1-04)
AMERICANS WITH DISABILITIES ACT (ADA)
GRIEVANCE FORM
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
INSTRUCTIONS
This is a printable form. Simply complete, print and send to: State Board of Equalization,
Internal Security and Audit Division, P.O. Box 942879, Sacramento, CA 94279-0054
GRIEVANT INFORMATION
GRIEVANT
ADDRESS
CITY STATE ZIP CODE
HOME PHONE (include area code) BUSINESS PHONE (include area code)
 
PERSON ALLEGING ADA VIOLATION (if other than grievant)
NAME
ADDRESS
CITY STATE ZIP CODE
HOME PHONE (include area code) BUSINESS PHONE (include area code)
 
BOE SERVICE, PROGRAM OR FACILITY
ALLEGEDLY IN VIOLATION
DATE ALLEGED VIOLATION OCCURRED
DESCRIPTION OF ALLEGED VIOLATION AND REQUESTED REMEDY
HAS THIS CASE BEEN FILED WITH THE DEPARTMENT OF JUSTICE OR OTHER GOVERNMENT AGENCY OR COURT?
YES NO
 
COMPLETE THE FOLLOWING IF YOU ANSWERED
“YES” TO THE PREVIOUS QUESTION
AGENCY OR COURT

CONTACT PERSON

ADDRESS
CITY STATE ZIP CODE
PHONE (include area code)
DATE FILED
OTHER COMMENTS
 

SIGNATURE DATE
   

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