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APPENDIX B AMERICANS WITH DISABILITIES ACT SERVICE DELIVERY DISCRIMINATION COMPLAINT FORM (Please print. Separate sheets of paper may be used if more space is needed.) NAME: ADDRESS: CITY, STATE, ZIP: PHONE (INCLUDE AREA CODE): EMAIL ADDRESS (OPTIONAL): Name of Department and/or employee against whom the complaint is filed: Description of the action or treatment which you think was discriminatory. Include information about who, what, when, where, how, and why; as well as the names, addresses and phone numbers of any witnesses, if you know them. Description of the relief or satisfaction you would like: Signature: Date: You may call the Library Director at (406)388-4346 if you would like assistance completing this form. Please return the completed form to the Belgrade Community Library Director.