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Appendix A <br />City of Sunny Isles Beach <br />Title A Complaint of Discrimination <br />Complainant Name:Address: <br />Phone Number: <br />E-mail Address: <br />Please list the names, addresses and phone numbers of any witnesses: <br />Location of Incident: <br />Date of Incident: <br />Discrimination <br />Because of: <br />e Race € Color € Nation Origin € Sex € Age € Handicap/Disability <br />Income Status € Retaliation € Other <br />Please explain how, why, when and where you believe you were discriminated against. Include as <br />much background information as possible about the alleged acts of discrimination. Additional pages <br />may be attached if needed. <br />Complainant Signature: <br />Date of Signature: <br />Note: Alternate means of filing complaint, such as personal interviews or a tape recording of the <br />complaint, will be made available for persons with disabilities upon request. <br />City of Sunny Isles Beach <br />Title VI Program Plan <br />