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ADA Complaint Form

  1. First Name

  2. Last Name

  3. Address Street Number

  4. Address Street Name

  5. Street Type - Road, Street, Avenue Etc.

  6. Apartment Number

  7. City

  8. State

  9. Zip Code

  10. Insert Today's Date

  11. When did this event occur?

  12. Name of Individual Discriminated Against

  13. Describe Violation and Identify City Department Involved

  14. Name of Agency

  15. Insert Date Complaint was Filed with Agency

  16. Contact Person at the Agency

  17. Street Address of the Agency

  18. City

  19. State

  20. Zip Code

  21. Best way to reach you concerning the content in this form?*

    Best way to reach you concerning the content in this form? Please select Phone, Email, Mail or In-Person.

  22. Email Address

  23. Phone Number

  24. Digital Signature: I understand that the information contained in this form is accurate to the best of my knowledge.*

    Digital Signature: I understand that the information contained in this form is accurate to the best of my knowledge. Please select Confirm or Deny

  25. 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

  26. 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.

  27. Leave This Blank:

  28. This field is not part of the form submission.