2. Title VI Complaint Form
   Please fill out this form completely and as detailed as you are able.
4. 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.
6. Complainant Contact Information
   (Person discriminated against)
8. First Name*
9. Last Name*
11. Mailing Address*
13. City*
14. State*
15. Zip Code*
17. Daytime Phone*
18. Evening Phone
19. Email Address*
23. Person Discriminated Against
    (If other than the complainant listed above)
25. First Name
26. Last Name
28. Mailing Address
30. City
31. State
32. Zip Code
34. Daytime Phone
35. Evening Phone
36. Email Address
40. Incident Details
42. What was the discrimination based on?*

    (Check all that apply)

    1. Race/Color
    2. Gender
    3. Gender Identity

    1. Sexual Orientation
    2. National Origin
    3. Disability

    1. Age
    2. Religion
    3. Pregnancy

    1. Income Status
    2. Genetic Information
    3. Military Service
44. What City representative(s) are the person alleging were involved?*
46. Date of incident resulting in discrimination*
47. Time of Incident*
49. Describe how you were discriminated against. Who was responsible and what happened?*
    For additional space, attach additional sheets of paper.
51. Where did the incident take place? Please provide specific details.*
    (i.e. location, bus number, driver's name, etc.) For additional space, attach additional sheets of paper.
55. Witnesses
    If there were witnesses to the incident, please provide their contact information.
57. WITNESS 1:
59. First and Last Name
60. Email Address
62. Mailing Address
64. City
65. State
66. Zip Code
68. Daytime Phone
69. Evening Phone
71. WITNESS 2:
73. First and Last Name
74. Email Address
76. Mailing Address
78. City
79. State
80. Zip Code
82. Daytime Phone
83. Evening Phone
87. Did you file this complaint with another federal, state, or local agency or court?*

    1. Yes

    1. No
89. If the answer is yes, check the agency the complaint was filed with and provide agency contact information:

    1. Federal Agency
    2. Federal Court

    1. State Agency
    2. State Court

    1. Local Agency
    2. Other
91. If yes, list the name of the Agency or Court
92. Date Filed
94. Agency Mailing Address
95. City
97. State
98. Zip Code
99. Telephone Number
101. Contact Person
102. Email Address
104. Attorney Name (If you have representation)
105. Attorney Phone
107. Attorney Mailing Address
108. Attorney Email Address
112. Acknowledgement*

     1. I hereby certify that the above is a true and correct statement of my complaint under Title VI of the Civil Rights Act of 1964.
114. Name of Person Submitting this Form*
115. Date*
117. Please attach any supporting documents if applicable
Leave This Blank:


119. 1. Receive an email copy of this form.
120. Email address

     This field is not part of the form submission.

121. Submit Submit and Print

* indicates a required field