1

Name:

Name:

2

Address:

Address:

3

Telephone 1:

Telephone 1:

4

Telephone 2:

Telephone 2:

5

Email Address:

Email Address:

6

Are you filling out this form on your behalf?

Are you filling out this form on your behalf?

Yes

No

7

If you answered "no" to the previous question, please provide the name and the relationship of the person for whom you are complaining. Also, please explain why you are filing a complaint for someone else.

If you answered "no" to the previous question, please provide the name and the relationship of the person for whom you are complaining. Also, please explain why you are filing a complaint for someone else.

8

What was the discrimination about which you are complaining based on? Mark all that apply.

What was the discrimination about which you are complaining based on? Mark all that apply.

Race

Color

National Origin

9

What was the date of the alleged discrimination?

What was the date of the alleged discrimination?

10

Please explain as clearly as possible what happened and why you believe there was discrimination. Describe all persons who were involved. Include the name(s) and contact information of the person(s) who you believe did the discriminating (if known). Include the name(s) and contact information of any witnesses. You may also attach any written material or other information that you think is relevant to the complaint.

Please explain as clearly as possible what happened and why you believe there was discrimination. Describe all persons who were involved. Include the name(s) and contact information of the person(s) who you believe did the discriminating (if known). Include the name(s) and contact information of any witnesses. You may also attach any written material or other information that you think is relevant to the complaint.

11

Have you previously filed a Title VI complaint with GREAT?

Have you previously filed a Title VI complaint with GREAT?

Yes

No

12

Have you filed this complaint with any other Federal, State, or local agency, or with a Federal or State court?

Have you filed this complaint with any other Federal, State, or local agency, or with a Federal or State court?

Yes

No

13

If you have filed with complaint with a Federal, State or local agency, or a Federal or State court, please note which ones. Mark all that apply.

If you have filed with complaint with a Federal, State or local agency, or a Federal or State court, please note which ones. Mark all that apply.

Federal Agency

Federal Court

State Agency

State Court

Local Agency

14

If you identified any agency/court, please provide information about a contact person at the agency/court where the complaint was filed.

If you identified any agency/court, please provide information about a contact person at the agency/court where the complaint was filed.

15

Please add any other information that you feel is relevant.

Please add any other information that you feel is relevant.

16

This form requires an electronic signature. Please type your full name and today's date in the space provided.

 *

This form requires an electronic signature. Please type your full name and today's date in the space provided.

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