Title VI Complaint Form
TITLE VI – COMPLAINT FORM
Title VI of the Civil Rights Act of 1964 states that, “No person in the United States shall on the basis of race, color, national origin, be excluded from participation in, be denied the benefit of, or otherwise be subjected to, discrimination in any program, service, or activity receiving federal financial assistance.”
This form may be used to file a complaint with the City of Jennings, City Clerk’s Office, for alleged violations of Title VI of the Civil Rights Act of 1964. If you need assistance completing this form, please contact the City of Jennings at (314) 388-1164 or via FAX (314) 388-3999.
Only the complainant or the complainant’s designated representative should complete this form.
NAME
STREET ADDRESS
CITY STATE ZIP CODE
TELPHONE
EMAIL
Individual(s) discriminated against, if different from above (use additional page(s) if necessary):
NAME
STREET ADDRESS
CITY STATE ZIP CODE
TELPHONE EMAIL
PLEASE EXPLAIN YOUR RELATIONSHIP TO THE INDIVIDUAL(S) INDICATED ABOVE
Name of Agency and department or program that discriminated:
AGENCY AND DEPARTMENT NAME
NAME OF INDIVIDUAL (if known)
STREET ADDRESS
CITY STATE ZIP CODE
TELEPHONE
Dates of alleged discrimination:
DATES DISCRIMINATION BEGAN LAST OR MOST RECENT DATE OF DISCRIMINATION
Alleged Discrimination:
Complaints should be filed within 180 days pf the alleged discrimination. If you could not reasonably be expected to know the act was discriminatory within the 180-day period, you have 60 days after you became aware to file your complaint.
If your complaint is in regard to discrimination in the delivery of services or discrimination that involved the treatment of you or others by the agency or department indicated above, please indicate below the basis on which you believe these discriminatory actions were taken. (Check all that apply)
Example: If you believe that you were discriminated against because you are African American, you would
mark the box labeled Race or Color and write African American in the space provided.
Explain:
Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and others involved in the alleged discrimination. (Attach additional sheets if necessary and provide a copy of written materials pertaining to your case.)
TITLE VI Complaint Form 052021 FILLABLE.pdf Signature: Date:
Note: The laws enforced by this department prohibit retaliation or intimidation against anyone because that individual has either taken action or participated in action to secure rights protected by these laws. If you experience retaliation or intimidation separate from the discrimination alleged in this complaint or if you have questions regarding the completion of this form, please contact:
City of Jennings
City Clerk’s Office
2120 Hord Avenue
Jennings, MO 63136
(314) 388-1164 | (314) 388-3999 FAX