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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.