"Title VI Complaint Form" - DeKalb County, Georgia (United States)

Title VI Complaint Form is a legal document that was released by the County Government - DeKalb County, Georgia - a government authority operating within Georgia (United States). The form may be used strictly within DeKalb County.

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DeKalb County Government
Title VI
Complaint Form
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.”
Note: The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please
let us know. Complete and return this form to: Nichole Simms, Title VI Coordinator, DeKalb County Government, 1300 Commerce Drive Decatur, GA
30030.
1.
Complainant’s Name ____________________________________________________
2.
Address _____________________________________________________________
3.
City, State and Zip Code __________________________________________________
4.
Telephone Number (home) _____________________ (business) ___________________
5.
Person discriminated against (if someone other than the complainant)
Name _________________________________________________________________
Address________________________________________________________________
City, State and Zip Code _____________________________________________________
6.
Which of the following best describes the reason you believe the discrimination took place? Was it because of your:
a.
Race/Color ____________________________________________________
b.
National Origin _________________________________________________
c.
Other ________________________________________________________
7.
What date did the alleged discrimination take place? ______________________
8.
In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible. Please use the back of
this form if additional space is required.
9.
Have you filed this complain 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 Agency _____ State Court
______ Local Agency
10. Please provide information about a contact person at the agency/court where the complaint was filed.
Name _________________________________________________________________
Address________________________________________________________________
City, State and Zip Code ____________________________________________________
Telephone Number _______________________________________________________
11. Please sign below. You may attach any written materials or other information that you think is relevant to your complaint.
____________________________________
______________________
Complainant’s Signature
Date
DeKalb County Government
Title VI
Complaint Form
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.”
Note: The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please
let us know. Complete and return this form to: Nichole Simms, Title VI Coordinator, DeKalb County Government, 1300 Commerce Drive Decatur, GA
30030.
1.
Complainant’s Name ____________________________________________________
2.
Address _____________________________________________________________
3.
City, State and Zip Code __________________________________________________
4.
Telephone Number (home) _____________________ (business) ___________________
5.
Person discriminated against (if someone other than the complainant)
Name _________________________________________________________________
Address________________________________________________________________
City, State and Zip Code _____________________________________________________
6.
Which of the following best describes the reason you believe the discrimination took place? Was it because of your:
a.
Race/Color ____________________________________________________
b.
National Origin _________________________________________________
c.
Other ________________________________________________________
7.
What date did the alleged discrimination take place? ______________________
8.
In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible. Please use the back of
this form if additional space is required.
9.
Have you filed this complain 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 Agency _____ State Court
______ Local Agency
10. Please provide information about a contact person at the agency/court where the complaint was filed.
Name _________________________________________________________________
Address________________________________________________________________
City, State and Zip Code ____________________________________________________
Telephone Number _______________________________________________________
11. Please sign below. You may attach any written materials or other information that you think is relevant to your complaint.
____________________________________
______________________
Complainant’s Signature
Date