Discrimination Complaint Form
Please provide the following information in order for us to process your complaint. This form is available in alternate formats and multiple languages. Should you require these services or any other assistance in completing this form, please let us know.
Telephone Numbers: (Home)____________(Work)____________(Cell)____________
Please indicate the nature of the alleged discrimination:
Categories protected under Title VI of the Civil Rights Act of 1964:
☐Race ☐Color ☐National Origin (including limited English Proficiency)
Additional categories protected under related Federal and/or State laws/orders:
☐Disability ☐Age ☐Sex ☐Sexual Orientation ☐Religion ☐Ancestry
☐Gender ☐Ethnicity ☐Gender Identity ☐Gender Expression ☐Creed ☐Veteran’s Status ☐Background
Who do you allege was the victim of discrimination?
☐You ☐A Third Party Individual ☐A Class of Persons
Name of individual and/or organization you allege is discriminating:
Do you consent to the investigator sharing your name and other personal information with other parties to this matter when doing so will assist in investigating and resolving your complaint?
Please describe your complaint. You should include specific details such as names, dates, times, witnesses, and any other information that would assist us in our investigation of your allegations. Please include any other documentation that is relevant to this complaint. You may attach additional pages to explain your complaint.
Have you filed this complaint with any other agency (Federal, State, or Local)?
If yes, please identify:____________________________________________________
Have you filed a lawsuit regarding this complaint?
If yes, please provide a copy of the complaint.
Signature: ____________________________________ Date:___________________
Mail to: Title VI Coordinator, Northern Middlesex Metropolitan Planning Organization, 40 Church Street, Suite 200, Lowell, MA 01852
Email to: firstname.lastname@example.org