Title VI and ADA (Non-Discrimination) Complaint Form
Date of Complaint: ________________________________________________
Home Phone: _______________________
Other Phone: ________________________
Accessible Format Requirements (check all that apply)
Large Print Audio Tape TDD Other
Are you filing this complaint on your own behalf? ___ yes* ___ no
*If yes, go to Section III
If, no, please share the name and relationship of the person for whom you are complaining:
Reason you are complaining on behalf of this person (why are they not completing the form themselves):
Do you have the permission of the aggrieved party to file on their behalf? ___ yes ___ no
I believe the discrimination I experienced was based on (check all that apply):
______Race ______Color _____National Origin ____Disability
Date of Alleged Discrimination (Month, Date, Year): ___________________________
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please use the back of this form.
Have you previously filed a Title VI complaint with this agency? ___ yes ___ no
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? ___ yes ___ no
If yes, circle all that apply.
Federal Agency Federal Court State Agency State Court Local Agency
Please provide information about a contact person at the agency/court where the complaint was filed.
Name of Agency complaint is about: ____________________________
Contact Person: __________________________________________
Phone Number: __________________________________________
You may attach any written materials or other information that you think is relevant to your complaint.
Signature (required) Date (required)
Submit this form in person or mail to the address below:
Alison Smith, Director of Finance
2999 River Road West
Goochland, VA 23063