Nassau County, NY

TITLE VI COMPLAINT FORM

Title VI of the Civil Rights Act of 1964, and related Federal, State and local, statutes and regulations, as amended, require that no person in the United States of America shall, on the grounds of race, color, national origin, sex, age, disability, or income, be excluded from the participation in, be denied the benefits of, or be otherwise subject to discrimination under any program or activity, for which the County of Nassau receives Federal financial assistance. If you believe you have been discriminated against on the basis of race, color, national origin, sex, age, disability, income, or any other unlawful basis, please complete this form by providing the requested necessary information. In order to process your complaint completely and accurately, please fill out the form completely and legibly. Should you need assistance filling out this form, or if you have any questions about filing this complaint, please contact: Title VI Coordinator at 516-571-6497. Your complaint must be filed within one hundred eighty (180) days from the date of the alleged act of discrimination.

Section I: Complainant Information

First Name: *

Last Name: *

Street Address: *

City: *

State: *

Zip Code:*

Phone Number: *

Email Address: *

Is someone else helping you file this complaint? *

First Name: *

Last Name: *

Relationship to the Complainant: *

Street Address: *

City: *

State: *

Zip Code:*

Reason for Assisting Complainant with Form: *

Section II: Details Of Claim

Your claim of discrimination is based on (Choose all that apply): *

Race

Color

National Origin

Sex

Age

Disability

Income

Limited English Proficiency

Other

If You Selected Other Please Explain: *

Date of alleged discrimination: *

Location where the alleged discrimination took place: *

Please briefly describe the circumstances of the alleged discrimination: *

List any witness name(s) and telephone number(s):

Did you report or filed a claim about the alleged discrimination with any Employee, Department Head, or anyone else in Nassau County? *

If you checked “Yes”, please provide the name, and contact information of the department or person: *

If “Yes”, please attach a copy of any report that you filed or received: *

Have you filed a claim regarding this complaint with any federal, state or local government agency? *

If “Yes”, please provide the name and contact information of the agency: *

If “Yes”, please attach a copy of any report that you filed or received: *

Have you instituted a legal suit or court action regarding this complaint? *

If “Yes”, please provide the name of the action, the Index/File Number, and the Court where the action was filed: *

If “Yes”, please attach a copy of of the papers that were filed: *

Have you hired an attorney with respect to the allegations in the complaint? *

If “Yes”, please provide your attorney’s name, firm name, address, and telephone number: *

If you have any other information that you would like to provide, please state here:

All fields marked with a red asterisk (*) are required