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Title II Discrimination Complaint Form <br />Address: <br />County: <br />City: <br />State and Zip Code: <br />Telephone Number: <br />When did the discrimination occur? Date: <br />Describe the acts of discrimination providing the name(s) where possible of the individuals who <br />discriminated (use space on page 3 if necessary): <br />Have efforts been made to resolve this complaint through the internal grievance procedure of the <br />government, organization, or institution? <br />Yes No <br />If yes: what is the status of the grievance? <br />Page 2 of 4 <br />