Title VI Complaint Form

Required Information Name (complaintant):*
Home Address (street, apt.#, city, state, zip):
Date of alleged incident (or date range if this took place more than once):
In your own words, describe the alleged discrimination. Be sure to include how you believe you were treated differently:
Optional Information If applicable, name and title of person(s) who allegedly discriminated against you:
Location where the alleged incident took place:
Is this activity still on-going?
Discrimination was based on:
Please list any person(s) we may contact for additional information to support or clarify your complaint:
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 provide the name and phone number of the contact person at the agency/court where the complaint was filed: