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VILLAGE OF NASHVILLE
TITLE VI
DISCRIMINATION COMPLAINT FORM
In order for us to properly assist you in processing your complaint, the
following information is needed:
1. Complainant’s
Name:_______________________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number (home): _______________
(business): _______________________
2.Person discriminated against (if someone other than complainant):
Name: _______________________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number (home): __________________
3. What is the name and location of Village Department or agency that you
believe discriminated against you?
Name: _______________________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number: ___________________
4. Which of the following best describes the reason you believe the
discrimination took place?
Was it because of your:
a. Race/Color (specify) _________________________________________________
b. National Origin (specify) ______________________________________________
5. What date did the alleged discrimination take place?
_____________________________________________________________________
_____________________________________________________________________
6. In your own words, describe the alleged discrimination. Explain what happened
and whom you believe was responsible.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Do you have any witnesses to verify your allegations?
YES______ NO _______
If YES,
Name: _______________________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number: _________________
7. Have you tried to resolve this complaint through the internal grievance
procedure at the accused department or agency?
YES______ NO _______
If YES, what is the status of the grievance?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Name and title of the person handling the grievance procedure.
Name: _______________________________________________________________
Title: ________________________________________________________________
Telephone Number: ___________________
8. Have you filed this complaint with any other federal, state or local agency;
or with any federal or state court?
YES______ NO _______
If YES, check all that apply:
Federal Agency ___ State Court ___ State Agency ___
Federal Court ___ Local Agency ___
Please provide information about a contact person at the agency/court (where the
complaint was filed)
Name: _______________________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number: ___________________
_
9. Do you intend to file this complaint with another agency?
YES______ NO _______
If YES, when and where do you plan to file the complaint?
Date: _________________
Agency: _____________________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number: ___________________
10. Has this complaint been filed with this agency before?
YES______ NO _______
If YES, when? Date ______________
11. Have you filed any other complaints with this agency?
YES______ NO _______
If YES, when and against whom were they filed?
Date: ________________
Name: _______________________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number: __________________
Give a brief description of the other complaint.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What is the status of the other complaint?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
12. Are you represented by an attorney with regard to anything related to this
matter?
YES______ NO _______
If YES, please fill in the following:
Attorney’s Name: ______________________________________________________
Address: _____________________________________________________________
City, State, Zip Code: __________________________________________________
Telephone Number: ___________________
13. Please sign below. You may attach any written materials or other information
that you think is relevant to your complaint.
__________________________________
_______________
Complainant Signature
Date
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VILLAGE
OF NASHVILLE, MICHIGAN
