Title VI Complaint Form

Title VI Complaint Form

  1. Title VI Complaint Form

  2. Person discriminated against (if someone other than the complainant):
  3. Reason:*

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

  4. What date did the alleged discrimination take place?

  5. 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.

  6. If yes, check all that apply:
  7. Please provide information about a contact person at the agency/court where the complaint was filed.
  8. Confirm Signature*

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

  9. Leave This Blank:

  10. This field is not part of the form submission.