Title VI Consolidated Civil Rights Complaint Form

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
Should be Empty: