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ADA GRIEVANCE FORM <br /> CITY OF SOUTH BEND,INDIANA <br /> Today's Date: <br /> Complainant: <br /> Address: <br /> City, State, Zip: <br /> Telephone and E-mail: <br /> Individual Discriminated Against: <br /> (If Different from Complainant) <br /> Address: <br /> City, State, Zip: <br /> Telephone and E-mail: <br /> Alleged Violation: Date(s)&Approximate Time <br /> of Occurrence: <br /> Detailed Description of Violation and City Department Involved: <br /> Requested Action by City to Correct Violation: <br /> Has Complaint been filed with State or Federal Agency: Yes No <br /> Name of Agency: Date Filed <br /> Contact Person: <br /> Signature; <br /> If there are witnesses,please list names and addresses separately. <br />