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Title VI Complaint Form
Title VI of the Civil Rights Act of 1964 states “No person in the United States shall, on the ground of
race, color, or national origin, be excluded from participation in, be denied the benefits of, or be
subjected to discrimination under any program or activity receiving Federal financial assistance.”
Title VI, 42 U.S.C. § 2000d et seq.
Please provide the following information necessary in order to process your complaint. A formal
complaint must be filed within 180 days of the occurrence of the alleged discriminatory act.
If you need assistance completing this form please contact the Title VI/ ADA Coordinator below:
Title VI / ADA Coordinator
C/o County Auditor- Karla Weiss
Winnebago County Courthouse
126 S. Clark St.
Forest City, IA 50436
(641) 585-3412
auditor@winnebagocountyiowa.gov
What is the discrimination based on?
Race/Color National Origin Sex Disability Income Status
Limited English Proficiency Age
Date of the alleged discrimination:
Location of alleged discrimination:
Agency or person that was responsible for the alleged discrimination:
______________________________________________________________________________
Have you filed this complaint with any other Federal, State, or local agency? Yes | No
If yes, whom? ________________________________________________________________
Person(s) discriminated against (if other than complainant):
