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Title VI Complaint Form

2. Title VI of the Civil Rights Act of 1964, and other related laws and regulations, provide that no person shall on the grounds of race, color, national origin, sex, age, disability, and income be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity receiving federal funds. The purpose of this form is to assist you in filing a complaint with the Town’s Title VI Coordinator. You are not required to use this form. A letter containing the same information is sufficient. However, the information requested must be provided, whether this form is used. ADA assistance is available upon request. You may file a complaint against the Town, a Town contractor, or a Town subrecipient of federal funds. All complaints must be filed within 180 days of the occurrence of the alleged act or a waiver requested as indicated below. Send All Complaints To: Town of Fuquay-Varina – Finance Director, 134 N. Main Street, Fuquay-Varina, NC 27526
4. 1. Complainant's Name and Address
   Please complete.
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip Code
15. Home Phone Number
16. Work Phone Number
18. Cell Phone Number*
22. 2. Person(s) Discriminated Against, if Different from Above.
    Please complete.
24. First Name*
25. Last Name*
27. Address*
29. City*
30. State*
31. Zip Code
33. Home Phone Number
34. Work Phone Number
36. Cell Phone Number*
40. 3. Town Department, Contractor or Subrecipient that Discriminated
    Please complete.
42. First Name
43. Last Name
45. Address
47. City
48. State
49. Zip Code
51. Home Phone Number
52. Work Phone Number
54. Cell Phone Number
58. 4. Indicate the reasons you believe the discriminatory action(s) occurred.

    1. Race/Ethnicity
    2. National Origin

    1. Sex
    2. Religion

    1. Age
    2. Disability
62. 5. To Your Best Recollection. List the Date(s) the Discrimination Took Place
64. Earliest Date of Discrimination.
66. Most Recent Date of Discrimination.
70. 6. Explanation of Discrimination that Occurred
    Please explain as clearly as possible what occurred, who was involved, why you believe it occurred, and how you (or another) were discriminated against. Be sure to include how other persons were treated differently than you. (Please use additional sheets of paper, if necessary, and attach a copy of any written materials pertinent to your claim).
72. Upload Additional Information
76. 7. Timeframe for Complaints of Discrimination
    Complaints of discrimination must generally be filed within 180 days of the alleged discrimination. If the most recent date of discrimination listed above is more than 180 days ago, you may request a waiver of the filing requirement. If you wish to request a waiver, please explain why you waited until now to file your complaint.
80. 8. Sign and Date the Complaint
    By submitting this form to the Town of Fuquay-Varina, you are signing the form.
82. Print First and Last Name
Leave This Blank:


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

    This field is not part of the form submission.

86. Submit Submit and Print | Go Back