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Americans with Disabilities Act Discrimination Complaint Form

  1. Person Filling out this form

  2. Please enter name, address and phone number

  3. Discriminatory Incident

  4. Government, organization, institution or business which you belived discriminated

  5. Has the complaint been filed with another bureau of the Department of Justince or any other Federal, State, or local civil righst agency or court?*

  6. Leave This Blank:

  7. This field is not part of the form submission.