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Title II of the Americans with Disabilities Act <br />Section 504 of the Rehabilitation Act of 1973 <br />Discrimination Complaint Form <br />Instructions: Please Pill out this form completely, in black ink or type. Sign and return to the <br />address on page 3. <br />Complainant: <br />Address: <br />City, State and Zip Code: <br />Telephone: Home: <br />Business: <br />Person Discriminated Against: <br />(if other than the complainant) <br />Address: <br />City, State, and Zip Code: <br />Telephone: Home: <br />Business: <br />Government, or organization, or institution which you believe has discriminated: <br />Name: <br />