Brevard County Title VI Complaint Form
Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, or national origin in
programs and activities receiving Federal financial assistance. Specifically, Title VI states that "no person in the
United States shall, on the ground of race, color, or national origin, sex, age, disability, religion, income or
family status, be excluded from participation in, be denied the benefits of, or be subjected to discrimination
under any program or activity receiving Federal financial assistance" (42 U.S.C. § 2000d).
Before completing this form, please read Brevard County's Title VI Complaint Procedures located on our
website or by visiting our office.
The following information is necessary and required to assist in processing your complaint. If you require
assistance in completing this form, please contact us at the phone number listed. Complaints must be filed
within 180 calendar days after the dated alleged discrimination occurred.
Section 1
First Name Last Name
Street City State Zip Code
Telephone (Home) Telephone (Work)
Email Address
Accessible Format Requirements (Choose all that apply)
Large Print Telecommunication Device Audio Tape Other
Section 2
Are you filing this complaint on your own behalf? Yes No
*If you answered "yes" to this question, go to Section III.
If not, please supply the name and relationship of the person for whom you are complaining
Please explain why you have filed for a third party
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a
third party.
I confirm this to be true
