Title VI Consolidated Civil Rights Complaint Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Person Discriminated against (if other than the complainant)
Discriminatory Incident
Government, organization, institution, or business which you believe has discriminated
Government, organization, institution, or business physical address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Government, organization, institution, or business Phone
-
Area Code
Phone Number
When did the discrimination occur? (date)
-
Month
-
Day
Year
Date
Primary type of disability
Issue
Describe the acts of discrimination
Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization, institution, or business?
Yes
No
Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?
Yes
No
Name of Agency or Court if applicable
Submit
Should be Empty: