Title VI

Form

SECTION I
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Home
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number Work
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number Cell/Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Accessible Format Requirements? Large Print?
TTD?
Audio Tape?
Other?
Are you filling this complaint on your own behalf?

SECTION II Are you filing this complaint on your own behalf?
Name

First NameLast Name
If you answered "yes" to this question, to to Section III. If not, please supply the name and relationship of the person for whom you are complaining.
Name
Relationship blanks
Please explain why you have filed for a third party?
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party

Section III I believe the discrimination I experienced was based on (check all that apply):
Date of the alleged disrimination

MonthDayYear
Explain as clearly as possible what happened and why you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.

SECTION IV Have you previously filed a non-discrimination complaint with this agency?
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court?
If yes, check all that apply:
Please provide information about a contact person in the agency/court where the complaint was filed.
Name
Title blanks Agency blank
Address blanks Telephone blank

SECTION VI Name of agency complaint is against:
Contact Person
Title blanks Telephone Number blank
You may attach any written materials or other information that you think is relevant to your complaint.
File Upload

Cancelof
Signature
Date

MonthDayYear
Date
If information is needed in another language, contact Rose Jenkins at 504-207-4900. Please submit this form to:

Jefferson Council on Aging, Attn: Rose Jenkins, 6620 Riverside Drive, Suite 107, Metairie, LA 70003
Should be Empty:

Form