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Title VI Discrimination Complaint Form

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This form has been modified since it was saved. Please review all fields before submitting.

Steps

1. Step One This section is complete This section is incomplete
2. Step Two This section is complete This section is incomplete
3. Step Three This section is complete This section is incomplete

Step One

Contact Information
Name*
Email Address
Address
City
State
Zip Code
Phone Number
Are you filing this complaint on your own behalf?*
1. Yes
2. No
If you answered yes to this question, continue to Step 2.
If not, please supply the name and relationship of the person for whom you are filing a complaint.
Please explain why you have filed for a third party.
Continue

Step Two

Incident Information
I believe the discrimination I experienced was based on:*
Check all that apply.
1. Race
2. Sex
3. Color
4. National origin
5. Disability
6. Religion
7. Age
8. Sexual orientation
9. Income
10. Ability to speak English
11. Status as a parent
12. Other
If you chose other, please describe:
Date of alleged incident:
Date of alleged incident:
Agency or person(s) responsible for the alleged discrimination:
Name
Email Address
Address
City
State
Zip Code
Phone Number
Describe the alleged discrimination.
Please explain what happened, why you believe it happened, and how you were discriminated against. Indicate who was involved. Be sure to include how you feel other persons were treated differently than you.
What remedy are you seeking for the alleged discrimination?
Please note that this process will not result in the payment of punitive damages or financial compensation.
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Step Three

List any other people that we should contact for additional information in support of your complaint.
Please include contact information including email address, phone, and mailing address.
Name
Email Address
Address
City
State
Zip Code
Phone Number
Additional Information
List any other agencies with whom you have filed this same complaint.
Agency Name
Email Address
Address
City
State
Zip Code
Phone Number
Additional Information

Leave This Blank:

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

This field is not part of the form submission.
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Bothell, WA 98011
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