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                                         Americans With Disabilities Act (ADA) Title II

                                                  Grievance Form
Purpose: Use this form to file a grievance if you find that the Franchise Tax Board has not provided adequate
accommodation for a disability.

Instructions: Complete this form, print it, sign it and mail to:

                                   FRANCHISE TAX BOARD
                                   EQUAL EMPLOYMENT OPPORTUNITY OFFICE MS A163
                                   PO BOX 550
                                   SACRAMENTO CA 95812-0550


                                                     Grievant Information
Grievant Name


Address                                                            City                                 State    ZIP Code


Home Phone (include area code)                                     Business Phone (include area code)

(          )          ­                                            (        )       ­


                                    Person (other than Grievant) Alleging an ADA Violation
Name


Address                                                            City                                 State    ZIP Code


Home Phone (include area code)                                     Business Phone (include area code)

(          )          ­                                            (        )       ­


                                    FTB Service, Program or Facility Allegedly in Violation
Date Alleged Violation Occurred (dd/mm/yyyy)


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


FTB 5722 C1 (NEW 06-2005) SIDE 1
                    If You Answered "Yes" to the Previous Question, Complete the Following
Agency or Court


Contact Person


Address                                                 City                        State   ZIP Code


Phone (include area code)                               Date Filed (dd/mm/yyyy)

(          )          ­
Other Comments




Signature ______________________________________________________________ Date: ___________________




FTB 5722 C1 (NEW 06-2005) SIDE 2