GRIEVANCE/COMPLAINT FILED UNDER THE AMERICANS WITH DISABILITIES ACT JD-ES-263 Rev. 6-12 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions File this form with the Director, Human Resource Management Unit, 90 Washington Street, Hartford, Connecticut 06106, (860) 706-5280, no later than ten (10) days after the act or decision complained about. Attach additional documents if necessary. Name of person filing complaint Telephone Address (city) (state) (zip) E-mail (optional) Describe the alleged discriminatory act or decision (include dates, locations, names and contact information of witnesses use additional page(s), if necessary.) What remedy or solution are you requesting? Signed (Signature of person filing this complaint) Date signed 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: Director of the Human Resource Management Unit, or Director's Designee Dated The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/. American LegalNet, Inc. www.FormsWorkFlow.com