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ADA Grievance Form
Complainant Information
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone Number:

Email Address:

Nature of Disability:
 
Alternate Contact Information
First Name:
Last Name:
Address:

City:

State:
Zip:
Phone Number:
Email Address:
 
Incident Information
Location of Alleged Discrimination:

Date and Time of Alleged Discrimination:
Please describe the way in which you believe you were denied the benefit, service, program, or activity of the Superior Court in Pinal County, or have otherwise been subject to discrimination as a person with a disability by the Superior Court in Pinal County:
Please state, if known, the names or positions of any employees involved in the incident, as well as names, addresses, and telephone numbers of any witnesses to any such incident, if necessary:
 
    
 

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