Section I: Name (required) Address (required) Phone (Home) (required) Phone (Work) (required) Email (required) Accessible Format Requirements? (required)—Please choose an option—Large PrintAudio TapeTDDOther Section II: Are you filing this complaint on your own behalf? —Please choose an option—YesNo If you answered yes to the previous question, go to Section III. If not, please supply the name and relationship of the person for whom you are complaining. 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. —Please choose an option—YesNo Section III I believe the discrimination I experienced was based on (check all that apply): RaceColorNationl Origin Date of Alleged Discrimination: 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 IV Have you previously filed a Title VI complaint with this agency? —Please choose an option—YesNo Section V Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? —Please choose an option—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 Title Agency Address Phone Section VI Name of agency complaint is against Contact person Title Phone Δ Notice to the Public – Appendix GDownload Title VI Complaint ProcedureDownload Title VI Complaint FormDownload Language Assistance PlanDownload
