TITLE VI COMPLAINT FORM
If you feel that you have been discriminated against by the Town of
Brookhaven, please provide the following information in order to assist us in
processing your complaint and send it to the address provided:
Title VI of the 1964 Civil Rights Act provides that no person in the United States shall, on the
grounds of race, color, sex, national origin, age, marital status, disability, sexual orientation,
parental status, family medical history or genetic information, political affiliation, military service
or any other non-merit based factor, be excluded from participation in or be denied the benefits of
or be otherwise subjected to discrimination under any program or activity receiving Federal
financial assistance.
1. Your Name and Address:
Name: ______________________________________________________________________
Address: _____________________________________________________________________
Telephone No.: Home _______________ Mobile ________________ Work _______________
2. Person(s) Discriminated Against, if different from above:
Name: ______________________________________________________________________
Address: _____________________________________________________________________
Telephone No.: Home _______________ Mobile ________________ Work _______________
Please Explain your Relationship to this Person: _____________________________________
____________________________________________________________________________
____________________________________________________________________________.
Check off the appropriate category as to which your complaint pertains, and then provide
a description, explaining as clearly as possible, what occurred and why you believe it
happened and how you were discriminated against. Provide the name(s) of and witness(es)
or other person(s) involved in the alleged discrimination.
3. Does your complaint concern discrimination in the delivery of services or in other
discriminatory actions of the department or agency in its treatment of you or others?
________ Race/Ethnicity ________ Income Status ________Sex Orientation
________ Sex ________ Disability ________LEP
________ National Origin ________ Age ________Genetic Info
Explain: (If necessary, attached additional sheets of paper)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
Please list below any persons (witnesses, employees or others), if known, whom we may contact
for additional information to support or clarify your complaint. Include name, address, and a
phone number.
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
4. What is the most convenient time and place for us to contact you about this complaint?
______________________________________________________________________________
_____________________________________________________________________________.
5. To the best of your recollection, on what date(s) did the alleged discrimination take place?
Earliest Date of Discrimination: ___________________________________________________
Most Recent Date of Discrimination: _______________________________________________
6. Complaints of discrimination must be filed within 180 (one hundred eighty) days of the
alleged discrimination. If the most recent date of discrimination, as noted above, is more than
180 (one hundred eighty) days ago, then you may request a waiver of the filing requirement.
If you wish to request a waiver, please use the space below to explain why you waited until
now to file your complaint.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. Do you have any other information that you think is relevant to our investigation of your
allegations?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
8. What remedy are you seeking for the alleged discrimination?
______________________________________________________________________________
______________________________________________________________________________
9. Have you, or the person allegedly discriminated against, filed the same or any other
complaints with other governmental offices (including, but not limited to, the Federal Transit
Administration, Federal Highway Administration, NYS Division of Human Rights, or the
Department of Civil Rights)?
_________ Yes __________ No
If yes, please state the name, address, and contact information of the agency where the complaint
was filed and the current status of that complaint:
Agency: ______________________________________________________________________
Contact Person: ________________________________________________________________
Address: ______________________________________________________________________
Telephone Number: _____________________________________________________________
10. If you have an attorney representing you concerning the matters raised in this complaint,
please provide the following information:
Attorney Name: ________________________________________________________________
Address: ______________________________________________________________________
Office Telephone No.: ___________________________________________________________
11. We cannot accept a complaint if it has not been signed. Please sign and date the complaint
form below.
____________________________________ ___________________________
Signature Date
____________________________________
Print Name
Please return the completed form to:
Town of Brookhaven
Department of Housing and Human Services
One Independence Hill
Farmingville, New York 11738
The Town encourages all persons to certify their complaints for all mail being sent through the
U.S. Postal Service as to ensure that all written correspondence can be tracked.
This form may be used to file a complaint with the Town of Brookhaven based on Title VI of
the Civil Rights Act of 1964 and the Civil Rights Restoration of 1987. However, you are not
required to use this form; a letter that provides the same information may be submitted to file
your complaint.
Note: The Town of Brookhaven prohibits retaliation or intimidation against anyone who takes
action or participated in action to secure the rights protected by the Town’s policies. Please
inform the Town of Brookhaven’s Personnel Department if you feel you were intimidated or
experience perceived retaliation with regards to filing this complaint.
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