Title VI Complaint Form

Title VI of the Civil Rights Act of 1964 states “No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”

Title 42 U.S.C. Section 2000d

Please provide the following information necessary in order to process your complaint. A formal complaint must be filed within 180 days of the occurrence of the alleged discriminatory act. Assistance is available upon request. Please contact NVTA at (707) 259-8631.

Title VI Complaint Form

Complainant's Name*
First Middle Last
Complainant's Home Address*
Street Address Address Line 2 City State ZIP Code
Email*
Telephone (Home):*
Telephone (Work):*
Person(s) discriminated against (if other than complainant)*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Telephone (Home):*
Telephone (Work):*
Which of these factors was the discrimination based on?*
- Race/Color
- National Origin
What was the date of the discrimination?*
MM slash DD slash YYYY
Location of the alleged discrimination*
Agency or person that who was responsible for alleged discrimination:*
Describe the alleged Discrimination. Explain what happened and whom you believe was responsible (for additional space, attach additional sheets of paper to this form.*
List names and contact information of persons who may have knowledge of the alleged discrimination.*
How can the complaint be resolved? How can the problem be corrected?
Upload any supporting documents or images in .jpg, .png, or .pdf format
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 20 MB.
Electronic Signature*
You must type your full name in this box, thereby signing this form electronically, in order for this submission to be accepted.
Enter today's date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Your browser is out-of-date. For optimal performance and an improved experience, please use a modern browser.

Title VI Complaint Form