Fillable TITLE VI COMPLAINT FORM (City of Dania Beach)

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TITLE VI COMPLAINT FORM (City of Dania Beach)

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TITLE VI COMPLAINT FORM
Section I
Name:_______________________________
Address: ___________________________
Please provide mailing address in the following format. Street Address, City. State, Zip Code
Telephone: (Please provide at least one number)
Cell:(_):__________________
Home(_)______________
Work ( )_________________
Electronic Mail (e-mail) Address:
______________
(To be used solely for the purposes of this complaint)
If we have additional questions, what is the best method to contact you: (Check all that apply)
Email Home Phone Cell Phone WorkPhone
If you are disabled and require an
accommodation, please check all applicable
formats.
Large
Print
AudioTape
TDD
Other Please explain
Section II
Are you filing this complaint on your own behalf? Yes______ No_______
*if you answered "Yes” to this question above, skip to Section III, below.
If not, please supply the following information about the person for whom you are complaining:
Name:
-_____________________________________________________
[Note: The person identified have shall be the subject of Section
Ill,
below; and will be
referred to as “you"
throughout this form
Address (Address, City, State, Zip_
____________________________________________________________
Phone Number:
Home:___________
Cell: _____________
Description of relationship (e.g. parent, sibling, spouse, lawyer, etc.)
______________________
Please explain why you have filed for a third party:
Yes □
No □
Section III
Please identify on what basis you believe you were discriminated against (Check all that apply):
□
Race
D
Color
D
National
Origin
Date of Alleged Discrimination (Month, Day, Year): _____________________
NOTE: YOU HAVE 180 DAYS FROM THE DATE OF THE INCIDENT TO FILE A
COMPLAINT
Explain as what happened and why you believe you were discriminated against Identify all persons
who were involved in the alleged discrimination, and describe their actions in detail. Provide the name
(s) and contact information (telephone number, email, and/or address) for any witnesses. You may attach
any written materials or other information that you think is relevant to
your
complaint.
If
more
space
is
needed,
please
use
the
back
of
this form
Section IV
Have you previously filed a Title VI complaint with this agency?
*If you answered "No" to this question above, skip to Section V,
below.
•
If "yes," please state how many complaints have been filed?
•
If "yes," has a violation ever been found?
Yes
·
Yes
No
·
No
Section V
Have you filed this complaint with any other Federal, State, or local agency, or with any court?
Yes
N
o*
If
you
answered
"No"
to
this
question, skip
to
Section
VI
If yes, check all that apply:
Federal Agency:
Federal Court State Agency
State Court Local Agency
Please provide a copy of the complaint, and/or the following contact information about the
agency/court where you filed the other complaint(s).
Name:
Title:
Agency:
Address:
Telephone:
Date filed:
If the matter was resolved, please provide a copy of the findings or order, and/or provide a brief
summary of the findings here
Page 3 of 4
Signature Date
Please submit this form, in person or via mail, to the address below:
Linda Gonzalez,
Human Resources and Risk Management Director and Tile VI Coordinator
City of Dania Beach
100 W Dania Beach Blvd.
Dania Beach, Fl. 33004
Phone: 954.924.6810 x3608
Page 4 of 4
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TITLE VI COMPLAINT FORM (City of Dania Beach)

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Completed 15 February 2021

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