To: _______________________________________ (Name of person receiving notice)

Of: _______________________________________ (Name of agency/business/organization)

Under all applicable state and federal laws, I made a request to _________________________ (name of person) of ________________________ (name of agency/business/ organization) for sign language interpreter services, as a reasonable accommodation. I informed _______________________(name) that the interpreter provided to me, __________________ (name if known) does not meet my needs and does not provide me with effective communication. I requested that I be provided with different interpreter who can provide me with effective communication. _______________________ (Name) told me to direct my complaints to the interpreter referral/service agency, ______________________ (name of agency, if known), because this entity has a contract with that interpreter referral agency.

Please be advised that I have no agreement or relationship with any interpreter referral/service agency, nor am I a party to any contract with any interpreter referral/service agency. I will not discuss the violation of my rights with any interpreter referral/service agency. This agency business/organization has the obligation to provide me with effective communication, pursuant to all applicable state and federal laws, including but not limited to the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973 (as amended), the Michigan Persons with Disabilities Civil Rights Act, and the Michigan Deaf Person’s Interpreter Act. Please provide me with effective communication now.

____________________________________
(Print Name)

____________________________________
(Signature)

____________________________________
(Date)

Copyright Celeste Johnson, 2003. Reprinted with permission. This form may be freely reproduced and distributed on the condition that this notice appears on all copies.