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Discrimination Comp aint Form <br /> o*troi' viaf,k:„No‘,'N:.Vxi-km:AiiiUzxV.ntrg-zrAszogagoiamivokw-./seim.:i:zgo-Ygoo4 <br /> Name: <br /> Address: <br /> Telephone(Home): Telephone(Work): <br /> Electronic Mail Address: <br /> Large Print 0 Audio Tape 0 <br /> Accessible Format Requirements? TDD E Other 0 <br /> Section II: <br /> Are you filing this complaint on your own behalf? Yes* 0 No 0 <br /> *If you 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. El Yes 0 No <br /> ',-areuthut <br /> I believe the discrimination I experienced was based on (check all that apply): <br /> Race 0 Color 0 National Origin 0 <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 /> $Sa.l:iiiiiiViiiNiitqtfaxVAEAVN5SD:N*itntMtddaia-Maaoataataag*hnSaipmvAge <br /> Have you previously filed a discrimination complaint with this <br /> agency? CI Yes El No <br />