Service Disabled Veteran Bottomline - Report Form

ASDV has received numerous reports of disrespect and abuse by Government and Private sector persons of Disabled in Service and Prisoner of War Veteran businessman (SDVE) and other disabled Veteran persons, especially when SDVE are seeking to pursue the benefits the U.S. Congress has directed in PL-106.50 and stressed in section 3 of PL 108-183. ASDV views and treats these experiences of "discrimination" as the most serious form of harm to SDVE attempting to pursue their rehabilitation as owners and operators of smaller businesses. In order to properly respond and to classify these reports, ASDV is establishing a basic format to record these reports for effective follow-up and action. Please click here for cases involving denial of emergency medical care. To report electronically proceed to the form below. To report via fax please print and transmit to ASDV at: (202) 543-5398 Date Complainant: First Name: Last Name: Street Address: City: State: Zip: Home Telephone: Business Telephone: Person Discriminated Against (if other than complainant): First Name: Last Name: Street Address: City: State: Zip: Home Telephone: Business Telephone: Discriminating Government, Organization or Institution: Name: Street Address City State Zip Telephone: When did discrimination occur? Date or Range of Dates: Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated: Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization or institution? Yes No If "yes" what was the grievance?: Grievance: Has this complaint been filed or do you intend to file with another organization or agency or the Department of Justice or any other Federal, State or local civil rights agency or court? Yes, I have filed Yes, I intend to file No, I have not filed and do not intend to file If "yes": Agency or Court: Address: City: State: Zip: Telephone: Date Filed: Is there another agency or court you have filed intend to file with? Yes, I have filed Yes, I intend to file No, I have not filed and do not intend to file If "yes": Agency or Court: Address: City: State: Zip: Telephone: Comments: Additonal Comments: