2. Instructions: To submit a Title VI complaint please fill out the form below.
4. 1. Name (complainant)
6. 2. Phone
7. 3. Home address (street, PO Box, city, state, zip)
9. 4. If applicable, name of person(s) who alledgedly discriminated againtst you
11. 5. Location and position of person(s), if known
12. 6. Date of incident
14. 7. Discrimination because of

    1. Race
    2. National Origin
    3. Color
    4. Other
15. Other, please specify
17. 8. Explain as briefly and clearly as possible what happened and how you believe you were discriminated against. Indicate who was involved. Be sure to include how you feel other persons were treated differently than you.
19. 9. Why do you believe these events occurred?
21. 10. What other information do you think is relevant to the investigation?
23. 11. How can this/these issue(s) be resolved to your satisfaction?
25. 12. Please list any person(s) we may contact for additional information to support or clarify your complain (witnesses). Include name, address and phone number.
27. 13a. Have you filed this complaint with any other federal, state, or local agency; or any federal or state court?

    1. Yes

    1. No
29. 13b. If yes, check all that apply

    1. Federal agency
    2. State Agency
    3. Local Agency

    1. Federal Court
    2. State Court
31. 13c. If filed at an agency and/or court. please provide information about a contact person in the agency/court where the complaint was filed. Include name, address, and phone.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field