Discrimination ADA/Title VI Complaint Form Discrimination ADA/Title VI Complaint Form Section I: Name * Name First Name First Name Last Name Last Name Address: * Telephone (Home): * Telephone (Work): * Electronic Mail Address: Large Print TDD Audio Tape Others Section II: Yes* No If Not, Please supply the Name and relationship of the person for whom you are complaining: If Not, Please supply the Name and relationship of the person for whom you are complaining: First Name First Name Last Name Last Name Relationship 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: Yes No Section III: I believe the discrimination I experienced was based on (check all that apply): Race Color National Origin Disability Date of Alleged Discrimination (Month, Day, Year): * 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. If more space is needed, please use the back of this form. Section IV: Yes No If yes, please provide any reference information regarding your previous complaint. Section V: Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court? Yes No If yes, check all that apply: Federal Agency: Federal Court: State Court: State Agency: Local Agency: Name Name First Name First Name Last Name Last Name Title: Agency: Address: Telephone: Section VI: Name of agency complaint is against: Name of person complaint is against: Title: Location: Telephone Number (if available): Signature * Date * Submit If you are human, leave this field blank.
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