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TITLE VI COMPLAINT FORM
(a red asterisk denotes a required field)
SECTION I: COMPLAINANT INFORMATION
First Name
Last Name
Street Address
City
State
Zip Code
Phone Number
Alternate Phone Number
Email Address
SECTION II: IDENTITY OF PERSON ALLEGING DISCRIMINATION
Are you filing this complaint on your own behalf?
Yes
No
.
Name of Person for Whom You Are Filing This Complaint
Address of Person for Whom You Are Filing This Complaint
Phone Number of Person for Whom You Are Filing This Complaint
Email Address of Person for Whom You Are Filing This Complaint
What is your relationship to the person for whom you are filing this complaint?
Do you have permission to file this complaint on behalf of the person you identified in this Section II?
Yes
No
SECTION III: ALLEGED DISCRIMINATION
Basis of Alleged Discrimination (Select all that apply.)
Race
Color
National Origin
Date(s) of Alleged Discrimination
Describe in detail the alleged discrimination, including the name and contact information of the person(s) who committed the alleged discrimination and the name and contact information of any witnesses.
SECTION IV: FILING OF COMPLAINT WITH OTHER AGENCIES AND/OR COURTS
Has this complaint been filed with any other federal, state, or local agency and/or any federal or state court?
Yes
No
.
Name of Each Agency/Court and Case/Complaint/Docket Number Issued
Attach any additional documentation relevant to your complaint.
One file only.
512 MB limit.
Allowed types: gif, jpg, png, bmp, pdf, doc, docx, avi, mov, mp3, wav.
Signature
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Date (Select date from the drop-down calendar.)
By clicking Submit, I certify that the above information and any attached documentation are true and correct to the best of my knowledge.
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