City of Pasadena
Title VI Non-Discrimination Plan
T6NDP
Page57of60
Appendix F
Title VI Discrimination Complaint Form
This form may be used to file a complaint with the City of Pasadena based on violations of Title VI of the Civil Rights
Act of 1964. Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be
expected to know the act was discriminatory within 180 days, you have 60 days after you became aware to file a
complaint. Return the signed form to the Attn: Azell Carter, Compliance Examiner, 1211 Southmore, Pasadena,
Texas 77502 If you need assistance completing this form, please call 713.475.4977.
Last Name First Name
Mailing Address City State Zip
Telephone Alternate Telephone Email Address
Please indicate the basis of your complaint:
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Race
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Color
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National Origin ☐ Ethnicity
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Age
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Gender
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Disability
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Income
Date(s) and place(s) alleged discriminatory action took place, including earliest date of discrimination and
most recent date of discrimination:
Name(s) of City Departments, Programs, and Individuals responsible for discriminatory action(s):
Please explain as clearly as possible how you were discriminated against. Describe the nature of the action,
decision, or conditions of the alleged discrimination. Include how you were treated differently from others
based on your protected status.
