Title II and Title VI Complaint Form

Section One : Contact Information

Section 1 of 4
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are you filing this complaint on your own behalf?
Name of the person you are filing this complaint for:

First NameLast Name
Please explain why you are filing for a third party, and your relationship to the individual you are filing on behalf of:
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Section Two: Complaint

Section 2 of 4
I believe the discrimination I experienced was based on (check all that apply):

Other
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 who discriminated against you (if known), as well as the names and contact information of any witnesses.
Type Your Response Here:
You may attach any materials/information you think is relevant to your complaint.

Cancelof

Section 3: External Agencies

Section 3 of 4
Have you filed a previous Title VI complaint against disABILITYsa?
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 list the agency/agencies where your complaint has been filed:
Please provide any information you have for a contact person at the external agency/court where the complaint was filed:
Name and Title

First NameLast NameTitle
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Submission

Section 4 of 4
I hereby attest that, to the best of my knowledge, the provided information is true.
Full Name (Print Signature)
Date

MonthDayYear
Date
Signature
Should be Empty:

Section One : Contact Information