Government

Title VI Discrimination Complaint Form

  • Complainant's Information 
    Name:
    Address:
    City/State/Zip Code:
    Telephone Number (Home)
    Telephone Number (Work)

    Person Discriminated Against (if someone other than complainant)
    Name:
    Address:
    City/State/Zip Code:
    Telephone Number (Home)
    Telephone Number (Work)
       
    Which of the following best describes the reason you believe the discrimination took place?
    Race/Color (specify):
    Sex:
    National Origin (specify):
       
    On what date(s) did the alleged discrimination take place?
       
    Describe the alleged discrimination.  Explain what happened and who you believe was responsible.  
       
    List names and contact information of persons who may have knowledge of the alleged discrimination.  

    Have you filed this complaint with any other federal, state or local agency, or with any federal or state court?  Check all that apply.
     
    Please provide information about a contact person at the agency/court where the complaint was filed.
    Name:
    Address:
    City/State/Zip Code:
    Telephone Number (Work):