Title VI Complaint Form

Please complete this form to the best of your ability. If you need translation or other assistance, contact Karen Wolf, the City of Trinidad's Title VI Coordinator.

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First Name*

Last Name*

Address*

City, State, Zip*

Phone*

Email*

Basis of Complaint (Click on all that apply)

Race

Color

National Origin

Sex/Gender

Age

Disability

Retaliation

Other: Please Explain

Who Discriminated Against You? (Please provide Name, Name of Organization, Address, and Phone)

How Were You Discriminated Against?

Where Did The Discrimination Occur?

Dates And Times Discrimination Occurred?

Were There Any Witnesses To The Discrimination? (Please provide Name, Organization/Title, and Phone)

How Would You Like To See This Situation Resolved?

Have You Filed Your Complaint, Grievance, Or Lawsuit With Any Other Agency Or Court?

Yes

No

If you answered yes to the above question, please provide the agency name, when it was filed, status (pending, resolved, etc.), result, if known, and complaint number if known

Do You Have An Attorney In This Matter? (Please provide Name, Phone, Address, City, Zip)

Signature

 

<a href="http://trinidad.co.gov/government/non-discrimination_policy/tile_vi_complaint_form.php">Your Link Name</a>