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L <br />Discri all in a tion 'ornplah- � �-orm <br />P" c' <br />Name: <br />Address: <br />Telephone (Home): <br />Telephone (Work): <br />Electronic Mail Address: <br />Large Print El Audio Tape 0 <br />Accessible Format Requirements? TDD 0 Other ❑ <br />k'. <br />*91 <br />- <br />Are you filing this complaint on your own behalf? Yes* El No F <br />*If answered "yes " to this question, go to Section III, <br />If not, please supply the name and relationship of <br />the person for whom you are complaining. <br />Please explain why you have filed for a third party: <br />Please confirm that you have obtained the permission of the <br />Aggrieved party if you are filing on behalf of a third party. 0 Yes F-1 No <br />R9"'915R!11"'.'k% <br />10- <br />I believe the discrimination I experienced was based on (check all that apply): <br />Race 0 Color El National Origin F <br />Date of Alleged Discrimination (Month, Day,Year): Click or tap here to enter text. <br />Explain as clearly as possible what happened and why you believe you were discriminated <br />against. Describe all persons who were involved. Include the name and contact information <br />of the person(s) who discriminated against you (if known) as well as names and contact <br />information of any witnesses. If more space is need, please use the back of this form. <br />Owg 1W g + <br />Have you previously filed a discrimination complaint with this <br />agency? ❑ Yes 0 No <br />ce <br />