Title VI Complaint Form

SECTION 2:
Are you filling this complaint on your own behalf?

Yes*No
*If you answered "Yes" to this question, go to Section 3.

If not, please supply the name and relationship of the person for whom you are complaining:
Name

First NameLast Name
Relationship
Please explain why you have filed for a third party:
Please confirm that you have obtained the permission of the aggrieved party of you are filing on behalf of a third party

YesNo

SECTION 3:
I believe the discrimination I experienced was based on (check all that apply):

RaceColorNational Origin
Date of Alleged Discrimination:

MonthDayYear
Date
Explain as clearly as possible what happened and why you believe 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 5
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
Please provide information about a contact person at the agency/court where the complaint was filed.
Name

First NameLast Name
Title
Agency
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

SECTION 6
Name of Agency complaint is against:
Contact Person
Title
Phone Number
Please enter a valid phone number.
You may attach any written materials or other information that you think is relevant to your complaint.
File Upload

Cancelof
Signature

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Date

MonthDayYear
Date
Should be Empty:

SECTION 1: