TITLE VI COMPLAINT FORM

Title VI of the Civil Rights Act of 1964 states “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.” Two Executive Orders extend Title VI protections to Environmental Justice, which protects persons of low income, and Limited English Proficiency (LEP).

Please provide the following information necessary to process your complaint. Assistance is available upon request. Complete this form and mail or deliver to Quisha Bryant, Director, City of Huntsville Department of Parking & Public Transit, 500 B Church St., Huntsville, AL 35801.

Complainant's Name

Home Phone Number

Business Phone Number

Person discriminated against (if other than complainant)

What was the discrimination based on? (Check all that apply):

Race/color

Sex

Disability

Elderly

National origin

Low income

Limited English Proficiency

Date of incident resulting in discrimination:

Describe how you were discriminated against. What happened and who was responsible?

Did you file this complaint with another federal, state or local agency; or with a federal or state court?

Provide the contact information of the person you filed the complaint with:

Date complaint was filed:

Sign the complaint in the space below. Attach any documents you believe supports your complaint.

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Signature date