Form Center

2. First Name
   First Name
3. Last Name
   Last Name
5. Street Number
   Address Street Number
6. Street Name
   Address Street Name
7. Street Type
   Street Type - Road, Street, Avenue Etc.
8. Apt #
   Apartment Number
10. City
    City
11. State
    State
12. Zip
    Zip Code
14. Today's Date
    Today's Date
    Insert Today's Date
15. Alleged Violation Date of Occurrence*
    Alleged Violation Date of Occurrence

    Alleged Violation Date of Occurrence
    When did this event occur?
17. Individual Discriminated Against
    Name of Individual Discriminated Against
18. Describe Violation and Identify City Department Involved*
    Describe Violation and Identify City Department Involved
20. Has complaint been filled with a State or Federal agency?*
    -- Select One --YesNo

    Has complaint been filled with a State or Federal agency? Please Answer Yes or No.
21. Name of Agency
    Name of Agency
22. Date Complaint was Filed
    Date Complaint was Filed
    Insert Date Complaint was Filed with Agency
24. Contact Person at the Agency
    Contact Person at the Agency
25. Address of the Agency
    Street Address of the Agency
27. City
    City
28. State
    State
29. Zip Code
    Zip Code
31. Best way to reach you concerning the content in this form?*

    1. Phone
    2. Electronic Mail
    3. Mail
    4. In Person

    Best way to reach you concerning the content in this form? Please select Phone, Email, Mail or In-Person.
32. Email Address*
    Email Address
33. Phone Number*
    Phone Number
35. Digital Signature: I understand that the information contained in this form is accurate to the best of my knowledge.*

    1. Confirm
    2. Deny

    Digital Signature: I understand that the information contained in this form is accurate to the best of my knowledge. Please select Confirm or Deny
37. 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
    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
39. Upon review, a formal written complaint containing the complainant's signature may be required to verify the authenticity of this complaint.
    Upon review, a formal written complaint containing the complainant's signature may be required to verify the authenticity of this complaint.
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field