Dupage County Title Vi Complaint Form - Dupage County Department Of Community Services Page 2

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Please describe the circumstances as you saw them:
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Please list any and all known witnesses’ names and contact information:
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What type of corrective action would you like to see taken?
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Please attach any documents you have which support the allegation, then sign and date this
form and send to the person listed on the first page of this form:
____________________________________
______________________________
Signature
Print your name
____________________________________
Date

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