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2. Title VI Complaint Form

   Title VI of the Civil Rights Act of 1964 states "No person in the United States shall, on the grounds 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 including subrecipients."

   If you believe that you have been discriminated against because of your race, color, or national origin (including limited English proficiency), by the City of Ferndale's programs or activities, you have the right to file a formal complaint.

   Please complete the the form below to the best of your ability.

4. Name
6. Address
8. City
9. State
10. Zip Code
12. Phone Number
13. Best time of day to contact you
15. Email Address
17. Basis of Complaint (check all that apply)

    1. Race
    2. Color
    3. National Origin (includes language access)
19. Date of alleged incident
    Date of alleged incident
23. Who discriminated against you?
25. Name
27. Name of Organization
29. Address
31. City
32. State
33. Zip Code
35. Phone Number
39. Explain what happened, why you believe it happened, and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. If you have any other information about what happened, please attach supporting documentation to the form. (Attach additional pages if more space is needed.)
41. Upload additional documents if needed.
43. 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.
45. List any other persons that we should contact for additional information in support of your complaint. Please list their names, phone numbers, address, email address below.
49. Have you filed a complaint, grievance, or lawsuit with any other agency or court?

    1. Yes
    2. No
51. Who?
52. When?
    When?
54. Status (pending, resolved, etc.)
55. Result, if known
57. Complaint number, if known
59. Do you have an attorney in this matter?
63. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
65. Electronic Signature
66. Date
    Date
Leave This Blank:


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

    This field is not part of the form submission.

70. Submit

* indicates a required field