Attachment 1 - Oct 2016
City of Edgewater
Title VI Program
Complaint of Discrimination
Complainant(s) Name:
Complainant(s) Address:
Complainant(s) Phone Number:
Complainant(s) Email:
Complainant's Representative's Name, Address, Phone Number and Relationship (e.g. friend, attorney, parent,
Name and Address of Agency, Institution, or Department Whom You Allege Discriminated Against You:
Names of the Individual(s) Whom You Allege Discriminated Against You (If Known):
Because Of:
National Origin
Sex Age
Income Family Status Religion Disability
Date of Alleged Discrimination:
Please list the name(s) and phone number(s) of any person, if known, that the City of Edgewater
could contact for additional information to
support or clarify your allegation(s).
Please explain as clearly as possible how, why, when and where you believe you were discriminated
against. Include as much background information as possible about the alleged acts of
discrimination. Additional pages may be attached if needed.
Complainant(s) or Complainant(s) Representatives Signature:
Date of Signature:
Send completed form to:
Julie Christine, Human Resources Director
104 N. Riverside Drive
Edgewater, FL 32132
Phone: 386-424-2400
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