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Discrimination ADA/Title VI Complaint
Discrimination ADA/Title VI Complaint
Name
Address
Telephone
Work Telephone
Email
Accessible Format Requirements
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TDD
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None
Are you filing this complaint on your own behalf?
Yes
No
If you answered "no" to the question above, please supply the name and relationship of the person for whom you are complaining. If "yes" please type 'N/A'
Please explain why you have filed for a third party. If you answered "no" please type 'N/A'
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. If you are not filing on behalf of a third party, please select 'N/A'
Yes
No
N/A
I believe the discrimination I experienced was based on (check all that apply)
Race
Color
National Origin
Disability
Date of Alleged Discrimination
Explain as clearly as possible what happened and why you believe you were discriminatetd against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses
Have you previously filed a Discrimination Complaint with this agency?
Yes
No
If yes, please provide any reference information regarding your previous complaint. If no, please type 'N/A'
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?
Yes
No
If yes please check all that apply
Federal Agency
Federal Court
State Court
State Agency
Local Agency
Federal Agency (If selected above. Type 'N/A' if not selected))
Federal Court (If selected above. Type 'N/A' if not selected))
State Court (If selected above. Type 'N/A' if not selected))
State Agency (If selected above. Type 'N/A' if not selected))
Local Agency (If selected above. Type 'N/A' if not selected))
Please provide information about a contact person at the agency/court where the complaint was filed
Agency Contact Name
Agency Contact Title
Agency Contact Organization/Agency
Agency Contact Address
Agency Contact Phone No.
Name of agency complaint is against
Name of person complaint is against
Title of person complaint is against
Address of agency/person complaint is against
Phone number of agency/person complaint is against
You may attach any written materials or other information that you think is relevant to your complaint
Please type your full name to affirm that the information in this form is true and accurate to the best of your knowledge
This form may be submitted in person or by mail to the address below, or submitted electronically through this website or at the email listed below. A physical copy of this form is available at Miami Town Hall. Micah Gaudet, Town Manager 500 W. Sullivan Street Miami, AZ 85539 (928) 473-4003 miamimanager@cableone.net
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