Tri River Transit Authority Ada Complaint Form Page 3
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1
2
3Local Agency (Specify agency)
☐
13. Please provide information about a contact person at the agency/court where the
complaint was filed.
Name:
Title:
Agency:
Telephone: (
)
Address
City:
State:
Zip Code:
You may attach any written materials or other information that you think is relevant to your
complaint.
Signature and date is required:
__________________________________________
___________________
Signature
Date
If you completed Questions 3, 4 and 5, your signature and date is required
__________________________________________
___________________
Signature
Date
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