Disability Discrimination Appeal Form
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1
2
3CITY OF BUFFALO
TITLE II AMERICANS WITH DISABILITIES ACT
DISABILITY DISCRIMINATION
APPEAL FORM
Instructions:
Please complete all parts of this form in black or blue ink or
type. Sign, date, and return to the address on page 3.
PERSON DISCRIMINATED AGAINST:
N
_______________________________________________________
AME
A
____________________________________________________
DDRESS
C
___________________ S
______________ Z
_____________
ITY
TATE
IP
T
(H)_____________________ (W)_______________________
ELEPHONE
*********************************************************
INDIVIDUAL FILING APPEAL:
(C
ONLY
OMPLETE
IF THE APPEAL IS BEING FILED BY A PERSON OTHER THAN THE
)
INDIVIDUAL DISCRIMINATED AGAINST
N
_______________________________________________________
AME
T
________________________________________________________
ITLE
F
_______________________________________________________
IRM
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