2. Title VI Notice of Public Rights

   Title VI of the 1964 Civil Rights Act requires that "No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." 
   
   If you believe that you have been subjected to discrimination under Title VI, you may file a written complaint by completing the following information and submitting the form. 

4. 1) Complainant's Information:
6. First Name*
7. Last Name*
9. Email Address
10. Telephone*
12. Address*
14. City*
15. State*
16. Zip*
18. 2) Person discriminated against: (if someone other than the complainant)
20. First Name
21. Last Name
23. Email Address
24. Telephone
26. Address
28. City
29. State
30. Zip
32. 3) Which of the following best describes the reason you believe the discrimination took place? Was it because of:*

    1. Race/ Color
    2. National Origin
    3. Other
34. If other, please describe:
36. 4) Please provide the month, date and year the alleged discrimination took place?*
    4) Please provide the month, date and year the alleged discrimination took place?
38. 5) In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.*
40. 6) Have you filed this complaint with any other federal, state or local agency or with any federal or state court?*

    1. Yes
    2. No
42. 7) If yes, check all that apply:*

    1. Federal Agency
    2. Local Agency
    3. Federal Court
    4. State Agency
    5. State Court
    6. Does Not Apply
44. 8) Please provide the below information for the contact person at the agency/court where the complaint was filed:
46. First Name*
47. Last Name*
49. Email Address*
50. Telephone*
52. Address*
54. City*
55. State*
56. Zip*
58. Signature (Type full name)*
59. Submission Date:*
    Submission Date:
Leave This Blank:


61. Submit

* indicates a required field