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<br />Saint Anthony Village ADA Grievance Form Page 1 <br />City of Saint Anthony Village <br />Title II of the Americans with Disabilities Act <br />Section 504 of the Rehabilitation Act of 1973 <br />Discrimination Complaint Form <br /> <br />Instructions: Please fill out this form completely, in black ink or type. Sign and return to the address on <br />page 3. <br /> <br />Complainant: _________________________________________________________________________ <br />Address: ____________________________________________________________________________ <br />City, State and Zip Code: _______________________________________________________________ <br />Telephone:___________________________________________________________________________ <br />Home: ______________________________________________________________________________ <br />Business: ____________________________________________________________________________ <br />Person Discriminated Against (if other than the complainant): __________________________________ <br />Address: ____________________________________________________________________________ <br />City, State, and Zip Code: _______________________________________________________________ <br />Telephone: Home: ________________________ Business: _______________________________ <br /> <br />Government, or organization, or institution which you believe has discriminated <br />Name: ______________________________________________________________________________ <br />Address: ____________________________________________________________________________ <br />County: _____________________________________________________________________________ <br />City, State and Zip Code: _______________________________________________________________ <br />Telephone Number: ___________________________________________________________________