Title VI Complaint Form

Section I:

Complainant Name

Street Address: Address1

Street Address: Address2

City/Town

State/Province

ZIP/Postal Code

Country

If other, please specify

Section II:

Please supply the name and relationship of the person for whom you are complaining

Please explain why you have filed for a third party:

Section III:

Please provide the date(s) and location(s) of the alleged discrimination, and the name(s) of the individual(s) who allegedly discriminated against you including their titles (if known).

Please provide the names, addresses, and telephone numbers of any witnesses.

Explain as clearly as possible what happened, how you feel you were discriminated against, and who was involved. Please include how other persons were treated differently from you.

Section IV:

Name:

Title:

Agency/Court:

Address:

Telephone Number:

Section V:

Name of the agency complaint is against:

Contact Person:

Title:

Telephone Number:

Complainant Signature:

Sign above