Fillable CITY OF GRE NACR ES E COMPLAINT OF (City of Greenacres)

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CITY OF GRE NACR ES E COMPLAINT OF (City of Greenacres)

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  • 19 check-boxes
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File type: PDF

U.S.A. forms for City of Greenacres

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CITY OF GRE
E
NACR
ES
_
_
_
___
___________
Bus. Number
_
COMPLAINT OF TITLE VI DISCRIMINATION
The CITY, as a recipient of federal financial assistance, is required to ensure that its
services and related benefits are distributed in a manner consistent with Title VI of the
Civil Rights Acts of 1964, as amended.
Any person who believes that he or she, individually or as a member of any specific class
of persons, has been subjected to discrimination under Title VI, on the basis of race, color,
or national origin, may file a written complaint with the CITY.
We are asking for the following information to assist us in processing your complaint. If
you need help in completing this form, please let us know.
1. Complainant
Name:
Street Address:
City, State, Zip Code:
Telephone:
E-mail Address:
2. Person discriminated against (if someone other than the complainant):
Name:
Street Address:
City, State, Zip Code:
Tel. Home
Number:
_____________
E-mail Address:
Color
Marital Status
Gender Identity or Expression
3. Are you represented by an attorney for this complaint?
Yes No
If yes, please complete the following:
Attorney’s Name:
Street Address:
City, State, Zip Code
Telephone Number:
4.
Which
of the
following
best describes the reason you believe the
discrimination
took place:
Nat
io
n
a
l
Ori
g
in Race
Sex
Disability Sexual Orientation
Political Affiliation
Religion
5. Date of the alleged discrimination:
6. In the space below, please describe the alleged discrimination. Explain what
happened and who you believe was responsible.
7. Have you filed a complaint of the alleged discrimination with a federal, state or
local agency; or with a state or federal court?
Yes No
If yes, check all that apply:
Federal Federal Court
State State Court
Local
Please provide the name of the Agency where you filed your complaint.
Name:
Contact Person:
Please sign below. You may attach any additional information you think is
relevant to your complaint.
Signature of Complainant Date
Submit your signed complaint and any attachments to:
Human Resources Director/ Title VI & ADA Officer
City of Greenacres
5800 Melaleuca Lane
Greenacres, FL 33463
Telephone: 561-642-2001
Fax: 561-642-2027
Deaf, Hard of Hearing, Deaf/Blind, or Speech Impaired (English, Spanish,
or French Creole): Please contact the CITY by calling toll-free to the
Florida Relay Service, 7-1-1
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CITY OF GRE NACR ES E COMPLAINT OF (City of Greenacres)

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Completed 19 February 2021

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