Title VI Complaint Form

Title VI Complaint Form
Title VI of the Civil Rights Act of 1964 requires that “no person in the United States shall, on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”

The following information is necessary to assist the City in processing a Title VI complaint. If any person needs assistance in filing a complaint, including interpretation or translation assistance, please contact the City’s Title VI Coordinator via email at TitleVICoordinator@Sammamish.us or by calling 425-295-0500.

Complaints may be submitted via mail, email, or in person to:

Title VI Coordinator
City of Sammamish
TitleVICoordinator@sammamish.us

425-295-0500

Mailing address:
801 228th Avenue SE
Sammamish, WA 98075-9509

Physical Address:
801 228th Avenue SE
Sammamish, WA 98075-9509
Section I
Complainant's Name

First NameLast Name
Complainant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Complainant's Main Phone Number
Please enter a valid phone number.
Complainant's Alternate Phone Number
Please enter a valid phone number.
Complainant's Email (optional)
example@example.com
Section II
Are you filing this complaint on your own behalf?

YESNO
If your answer is YES, go to Section III. If your answer is NO, please include yourname and relationship of the person for whom you are filing thiscomplaint:

First NameLast Name
Please explain below why you have filed on behalf ofsomeone else.
Please confirm you have obtained permission from the aggrieved party to submit this complaint.

YES, I have permission to file this claim.NO, I do not have permission to file this claim.
Section III
Which of the following best describes the reason youbelieve discrimination took place.

RaceColorEthnicityNational OriginSex / GenderSexual OrientationAgeDisabilityIncomeReligionMarital StatusVietnam Era VeteranDisabled VeteranLimited English ProficiencyRetaliationPolitical IdeologyOther
If Other, please describe:
What day did the alleged discrimination take place?

MonthDayYear
Date
What time did the alleged discrimination take place?

Hour Minutes

AM/PM Option
In your own words, describe the alleged discrimination.Explain what happened and who you believe was responsible. Attach additionalpages if more space is needed.
Witnesses or others involved – provide name, address,telephone number(s) and email (if available).
Have you filed this complaint with any other federal,state, or local agency; or with any federal or state court?

YesNo
If yes, check all that apply:

Federal AgencyFederal CourtState AgencyState CourtLocal Agency
Section IV
Please provide contact person information at the agency / court where the complaint was filed.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Attest the above statements are true:

By submitting this form, you attest the above statements made are true and factual to the best of your knowledge. This complaint will constitute a public record upon submittal to the City and may be subject to disclosure under the public records act (RCW 42.56) and in accordance with the City of Sammamish’s website privacy policy.
Signature
Date

MonthDayYear
Date
Should be Empty:

Title VI Complaint Form

Section I

Section II

Section III

Section IV