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Americans with Disabilities Act Complaint Form

Please use this form to file a complaint based on disability in the provision of services, activities, programs or benefits.
1. Contact Information
This question requires a valid email address.
2. Your claim is made against:
4. Are the circumstances of your complaint continuing?
6. Please attach any supporting data, if available.
7. Have you filed a claim regarding this complaint with a federal, state or local government agency?
8. Have you hired an attorney with respect to the allegations in the complaint?
9. Have you instituted a legal suit or court action regarding this complaint?
10. This complaint form was completed by: *This question is required.
Type your name as an electronic Signature