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Address Street Number
Address Street Name
Street Type - Road, Street, Avenue Etc.
Insert Today's Date
When did this event occur?
Name of Individual Discriminated Against
Describe Violation and Identify City Department Involved
Has complaint been filled with a State or Federal agency? Please Answer Yes or No.
Name of Agency
Insert Date Complaint was Filed with Agency
Contact Person at the Agency
Street Address of the Agency
Best way to reach you concerning the content in this form? Please select Phone, Email, Mail or In-Person.
Digital Signature: I understand that the information contained in this form is accurate to the best of my knowledge. Please select Confirm or Deny
If you require assistance completing this form or need an alternate format, please contact Attn: Transportation Department, City Hall, 166 Lincolnway, Valparaiso, IN 46383. (219)462-1161
Upon review, a formal written complaint containing the complainant's signature may be required to verify the authenticity of this complaint.
This field is not part of the form submission.
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