N4 Title VI Complaint Form - English

Title VI of the Civil Rights Act of 1964 states "No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." Please provide the following information necessary in order to process your complaint. Assistance is available upon request.

What was the discrimination based on? Check all that apply. *
Did you file this complaint with another federal, state or local agency, or with a federal or state court? *
If you answered yes, check agency that a complaint was filed with