Title VI / ADA Complaints

Name

Email Address

Street Address

City, State, Zip Code

Home Phone Number

Work Phone Number

Are you filing complaint on your own behalf? Are you filing complaint on your own behalf? Yes No

Please supply the name and relationship of the person for whom the complaint is being issued.

Please explain why you are filing for a third party.

Please confirm that you have obtained the permission of the aggrieved party. Please confirm that you have obtained the permission of the aggrieved party. Yes I have received permission No I have not received permission

I believe the discrimination experienced was based on (check all that apply): I believe the discrimination experienced was based on (check all that apply): Race Color National Origin Disability Other

If Other, please explain:

Date of alleged discrimination

Location where alleged discrimination took place.

Complaint Details Explain as clearly as possible what happened and why you believe that discrimination took place. Describe all person who were involved. Include the name and contact info of the person(s) that discriminated against you/other, as well as names contact info of any potential witnesses.

Have you previously filed a Title VI or ADA complaint with this agency? Have you previously filed a Title VI or ADA complaint with this agency? Yes No

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court? Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court? Yes No

If yes, check all that apply If yes, check all that apply Federal Agency State Agency Local Agency Federal Court State Court

Contact Name

Contact Title

Contact Agency

Contact Telephone

Contact Address (Street Address, City, St, Zip Code)

Name of Agency complaint is against:

Contact Person

Title:

Phone Number:

You may attach any written materials and/or other information that may be relevant to the complaint File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, wax, rar, wri. Max. file size: 2 MB

Signature (Please type your full name):