Fill - Free fillable Title VI Complaint Form PDF (Town of Brookhaven) PDF form

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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Fill Online, Printable, Fillable, Blank Title VI Complaint Form PDF (Town of Brookhaven) Form

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Fillable Title VI Complaint Form PDF (Town of Brookhaven)

Fill Online, Printable, Fillable, Blank Title VI Complaint Form PDF (Town of Brookhaven) Form

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