DISCRIMINATION COMPLAINT/ FEDERAL GRANTS JD-ES-284 Rev. 12-18STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reason-able accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.Instructions A program or activity supported by U.S. Department of Justice funds must comply with federal civil rights discrimination laws. Civil rights complaints may be reported by filing this form with the Director, Human Resource Management Unit, 90 Washington Street, Hartford, Connecticut 06106, (860)240706-5280 or by e-mail to Human.Resources@jud.ct.gov . Attach additional documents, if necessary. Name of person filing complaint Telephone number Mailing address (Number and street, or P.O. box; city; state; zip code)Subrecipient's Name, Address and Telephone Number (A subrecipient is a program or agency that receives funds from the Connecticut Judicial Branch.) Does your complaint involve ("x" one): Employment Services or BenefitsDoes your complaint involve ("x" one or more): Age Religion Mental or Physical Disability Race/Ethnicity Color National Origin Sex (gender) Gender Identity Sexual OrientationDescribe the alleged discriminatory act (include dates, locations, names and contact information of witnesses - use one or more additional pages, if necessary.) Signature of complainant (Person filing this complaint) Date signed Do not write below this line. The complaint is dismissed. The following resolution is offered and the matter is concluded: The above resolution has been offered but the matter is not concluded. The complainant has been told about the federal and state agencies that are available if he or she wants to pursue the matter further.Additional comments: By: (Director of Judicial Branch Human Resource Management Unit or designee) Dated E-mail address American LegalNet, Inc. www.FormsWorkFlow.com