Form DHS-866 at a glance
What it is: Complaint under Americans with Disabilities Act (Title II) and Section 504 Michigan Department of Human Services.
Who signs: Sign on Signature and enter the Date.
A filled-in Form DHS-866 example: a complaint about a county program
How to fill out Form DHS-866, box by box
Complainant
Enter Complainant Name, Address, City, State, Zip Code, and Telephone, Home and Business.
Person Completing This Form
If the person completing this form is other than the complainant, enter Person Completing This Form, Address, City, State, Zip Code, and Telephone, Home and Business.
County/Program that you believe has discriminated against you
Under County/Program that you believe has discriminated against you, enter Name, Address, County, City, State, Zip Code and Telephone Number.
When did the event occur
Under When did the event occur?, enter the Date.
Describe the event providing the name(s) where possible for the individuals who were involved. Use space on page 2 if necessary.
Has the complaint been filed with another agency or court
Mark Yes or No: Has the complaint been filed with the Michigan Department of Civil Rights or the Federal Department of Justice or any other federal agency or court?
If yes, give the name of agency or court, Contact Person, Address, City, State, Zip Code, Telephone Number and Date Filed.
Additional space for answers
Additional space for answers.
Do you intend to file with another agency or court
Mark Yes or No: Do you intend to file with another agency or court?
Enter Agency or Court, Address, City, State, Zip Code and Telephone Number.
Signature and date
Sign on Signature and enter the Date.
More rules for Form DHS-866
Fill out this form completely, in black ink or type. Sign and return it.
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability.
If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
Common questions about Form DHS-866
Where do I file it?
Return to: Office of Human Resources PO Box 30037 Lansing, MI 48909 Phone: (517) 335-3521 Fax: (517) 335-4673.
Is there a penalty?
Response: Voluntary. Penalty: None.
Sources
[1] Form DHS-866, Complaint under Americans with Disabilities Act (Title II) and Section 504, Michigan Department of Human Services (the Official source link on this page).