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Service Disabled Veteran Benefits Care Report

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.

To report electronically proceed to the form below.

To report via fax please print and transmit to ASDV at:

Fax: (415) 252-9705

Date
Complainant:
First Name:
Last Name:
Street Address:
City:
State:
Zip:
Email:
Home Telephone:
Business Telephone:

Person Discriminated Against (if other than complainant):
Date:
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

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?

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?

If "yes":
Agency or Court:
Address:
City:
State:
Zip:
Telephone:

Comments:

SDVA: Report Forms
 
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