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Title VI Complaint Form

  1. Title VI Complaint Form
    Please fill out this form completely and as detailed as you are able.
  2. Title VI of the Civil Rights Act of 1964 requires that "No person in the United States shall, on the grounds of race, color or national origin, to be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal assistance." The City further assures that discrimination does not occur on the basis of gender, gender identity, sexual orientation, age, religion, pregnancy, genetic information, military service, disability/handicap, or income status as provided by other pertinent non-discrimination directives.

    Complaints shall state, as fully as possible, the facts and circumstances surrounding the alleged discrimination. The City of Edmond will provide a written acknowledgement that we have received the complaint within ten working days.
  3. Complainant Contact Information
    (Person discriminated against)
  4. Person Discriminated Against
    (If other than the complainant listed above)
  5. Incident Details
  6. What was the discrimination based on?*
    (Check all that apply)
  7. For additional space, attach additional sheets of paper.
  8. (i.e. location, bus number, driver's name, etc.) For additional space, attach additional sheets of paper.
  9. Witnesses
    If there were witnesses to the incident, please provide their contact information.
  10. WITNESS 1:
  11. WITNESS 2:
  12. Did you file this complaint with another federal, state, or local agency or court?*
  13. If the answer is yes, check the agency the complaint was filed with and provide agency contact information:
  14. Acknowledgement*
  15. Leave This Blank:

  16. This field is not part of the form submission.