Fillable Lgl001 TITLE VI COMPLAINT ALLEGATION (Virginia Department of Motor Vehicles)

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Lgl001 TITLE VI COMPLAINT ALLEGATION (Virginia Department of Motor Vehicles)

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LGL 001 (08/01/2017)
TITLE VI COMPLAINT ALLEGATION
Purpose: The Department of Motor Vehicles (DMV) rejects discrimination in all of its programs and activities. Title VI of the 1964 Civil
Rights Act and related non-discrimination authorities prohibit discrimination on the basis of race, color, national origin, sex,
disability, age, low income, or limited English proficiency. Use this form to record any allegation or allegations of
discrimination. The information you provide allows us to process your complaint.
Instructions: Complete the form and submit it to: Virginia DMV Title VI Program Coordinator, 2300 West Broad Street, Richmond,
Virginia 23269.
You may attach any written materials or other information that you think is relevant to your complaint. Contact the DMV Title
VI Program Coordinator if you need assistance in completing this form. The DMV phone number is (804) 497-7100. For
deaf and hard of hearing customers, connect with the teletypewriter device (TTY) at 1-800-272-9268.
CONTACT INFORMATION
INDIVIDUAL COMPLETING FORM
FULL NAME (first last mi)(print) STREET ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER(s)
PERSON(s) DISCRIMINATED AGAINST,(if other than person completing form)(use separate sheet if necessary)
FULL NAME (first last mi)(print) STREET ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER(s)
PLEASE EXPLAIN YOUR RELATIONSHIP TO THIS PERSON(s)
COMPLAINT INFORMATION
Do you believe you were discriminated against because of your: (check all that apply)
Race/Color National Origin Sex Age
Disability Low Income Limited English Proficiency Other (explain below)
IF YOU CHECKED OTHER ABOVE, PLEASE EXPLAIN
What date did the alleged discrimination take place? (mm/dd/yyyy)
DESCRIBE WHAT HAPPENED AND WHO YOU BELIEVE WAS RESPONSIBLE (please use separate sheet(s) if needed)
LGL 001 (08/01/2017) -- Page 2 of 2
COMPLAINT INFORMATION (continued)
Have you filed this complaint with any other federal, state, or local agency, or with any federal or state court? YES NO
DATE COMPLAINT WAS FILED (mm/dd/yyyy)
WHO DID YOU FILE THIS COMPLAINT WITH?
If you answered YES, please provide the following information:
Please provide information about a contact person at the agency where the complaint was filed:
CONTACT PERSON FULL NAME (first last mi) STREET ADDRESS
CITY
STATE
ZIP CODE
DATE (mm/dd/yyyy)INDIVIDUAL COMPLETING FORM SIGNATURE
I certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate.
CERTIFICATION
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Lgl001 TITLE VI COMPLAINT ALLEGATION (Virginia Department of Motor Vehicles)

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Completed 30 July 2020

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