Title VI of the Civil Rights Act of 1964 states that “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.” If you believe you have been discriminated against, please provide the following information in order to assist Placer County in processing your complaint.
SECTION 1 (Please print clearly):
Name: ______________________________________________________________________________________
Address:______________________________________________________________________________________
City, State, Zip Code:______________________________________________________________________________________
Telephone Number: ______________________(Home) ______________________(Work)
Accessible format requirements? ____(Large print)____(Audio)_____(TDD)_____(Other)
SECTION 2
Are you filing this complaint on your own behalf? _____(Yes)_____(No)
If you answered yes to this question, go to Section 3.
If not, please supply the name and relationship of the person for whom you are complaining:
Name: ______________________________________Relationship:________________________________
Please explain why you have filed for a third party:__________________________________________________________________
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of the third party. _____(Yes)_____(No)
SECTION 3
I believe the discrimination I experienced was based on (check all that apply): _______ Race _______ Color_______ National Origin
Date, Time and Place of Occurrence: ______________________________________________________________________________
Name (s) and Title(s) of the person (s) who I believe discriminated against me: ________________________________________________________________________________________________________
________________________________________________________________________________________________________
The action or decision which caused me to believe I was discriminated against is as follows: (Please include a description of what happened and how your benefits were denied, delayed or affected):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Please list any and all witnesses’ names and phone numbers (if available):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What type of corrective action would you like to see taken?________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
SECTION 4
Have you previously filed a Title VI complaint with this agency? _____(Yes) _____(No)
SECTION 5
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____ 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:________________________________ Title:_______________________________
Agency:______________________________________________________________________
Address:______________________________________________________________________
Telephone Number:______________________________________________________________________
You may attach any written materials or other information that you think is relevant to your complaint. I believe the above information is true and correct to the best of my knowledge. Signature and date required below:
Signature:______________________________________________________________________
Printed Name:______________________________________________________________________
Date:______________________________________________________________________
Please submit this form in person at the address below or mail this form to:
Placer County Department of Public Works
3091 County Center Drive, Suite 220
Auburn, CA 95603