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Title II Discrimination Complaint Form <br />City, State and Zip Code: <br />Telephone Number: <br />Additional space for answers: <br />Signature: <br />Date: <br />Return to: <br />U.S. Depailinent of Justice <br />Civil Rights Division <br />950 Pennsylvania Avenue, NW <br />Disability Rights - NYAV <br />Washington, D.C. 20530 <br />Page 4 of 4 <br />