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<br />" <br />, , <br />.- -:';"- <br />'-":. <br />'" --'. \ <br />\ .'.. \ <br />( . ,I I), ;;~) <br /> <br />\ .\ <br />CITYOP sV:N:N"fISDES(]3~}lCJ{ <br /> <br />\..., .,/" _-:-::.:-:_-:<...\) "f/:;. <br />-',,- I=-:-O';'~/"-;" <br />, _ - __--"" ,\1 <br />"I_I\-! <br /> <br />Americans with Disabilities Act <br />Grievance Form <br /> <br />Today's Date: <br /> <br />Complainant: <br /> <br />Relationship to Individual discriminated against: <br /> <br />Address: <br /> <br />City <br /> <br />State <br /> <br />Zip <br /> <br />Telephone and E-mail: <br /> <br />Individual Discriminated Against: <br /> <br />Address: <br /> <br />Cily <br /> <br />State <br /> <br />Zip <br /> <br />Telephone and E-mail: <br /> <br />Alleged Violation: Date(s) and Place of Occurrence: <br /> <br />Description of Violation and City Department Involved: <br /> <br />Re<luestcd Action by City to Correct Violation: <br /> <br />Has Complaint Been Filcd with State or Federal Agcncy: <br /> <br />Yes <br /> <br />No <br /> <br />If Yes, Name of Agency: <br /> <br />Date Filed: <br /> <br />Contact Person: <br /> <br />Signature of Complainant: <br />U:\ATrORNEY\ADA Docs\SIB ADA Grievance Form.doc <br />