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.

Person discriminated against (if someone other than the complainant)
MM slash DD slash YYYY
What time did the alleged discrimination take place?(Required)
If yes, check all that apply:
Please provide information about a contact person at the agency/court where the complaint was filed.

Electronic Signature

Please type your First and Last Name
MM slash DD slash YYYY
I understand that checking this box constitutes a legal signature confirming that I acknowledge the truthfulness of the information provided.(Required)

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