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Title VI Complaint Form

  1. Please include the Street Address. Apartment, suite, building information is optional.

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

  3. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?

  4. If yes, check all that apply:

  5. You may attach any materials or other information that you think is relevant to your complaint.

  6. You may attach any materials or other information that you think is relevant to your complaint.

  7. Please sign. (By signing, you agree and acknowledge that 1) your form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.)

  8. Leave This Blank:

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