2. Title VI Complaint Form

4. Complainant's Name*
5. Email Address
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Business Number
16. Person discriminated against (if someone other than the complainant):
18. Name
20. Address
22. City
23. State
24. Zip Code
28. Reason:*

    Which of the following best describes the reason you believe the discrimination took place? Was it because of your:

    1. A. Race/Color
    2. B. National Origin
    3. C. Color
29. Date*
    Date

    What date did the alleged discrimination take place?

31. Describe the alleged discrimination*

    In your own words, describe the alleged discrimination. Explain what happened and who you believe was responsible. Please use the back of this form if additional space is required.

35. Have you filed this complaint with any other federal, state, or local agency, or with any federal or state court?*
    -- Select One --YesNo
36. If yes, check all that apply:

    1. Federal Agency
    2. Federal Court
    3. State Court
    4. Local Agency
    5. State Agency
38. Please provide information about a contact person at the agency/court where the complaint was filed.
40. Name
41. Email Address
43. Address
45. City
46. State
47. Zip Code
49. Phone Number
51. Complainant's Signature*
52. Date*
    Date
54. Confirm Signature*

    1. *

    I certify that the information contained is true and accurate as of this date.

Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field