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TITLE VI COMPLAINT FORM

2. City of Battle Creek
   Title VI Complaint Form

   Title VI Complaint Form

4. Title VI of the Civil Rights Act of 1964 states that "No person in the United States shall on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefit of, or otherwise be subjected to discrimination in any program, service, or activity receiving federal assistance."
   This form may be used to file a complaint with the City of Battle Creek based on violations of Title VI of the Civil Rights Act of 1964. You are not required to use this form; a letter that provides the same information may be submitted to file your complaint. Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to know the act was discriminatory within 180 day period, you have 60 days after you became aware to file your complaint.

   This form may be used to file a complaint with the City of Battle Creek based on violations of Title VI of the Civil Rights Act of 1964. You are not required to use this form; a letter that provides the same information may be submitted to file your complaint. Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to know the act was discriminatory within 180 day period, you have 60 days after you became aware to file your complaint.

6. If you need assistance completing this form, please contact Ted Dearing by phone at (269)966-3378 or via e-mail at tedearing@battlecreekmi.gov

   If you need assistance completing this form, please contact Ted Dearing by phone at (269)966-3378 or via e-mail at tedearing@battlecreekmi.gov

8. Name

9. Date

11. Address

13. City

14. State

15. Zip Code

17. Telephone (home)

18. Telephone (work)

20. Individual(s) discriminated against, if different than above.

    1. Click here if different than above

22. Name

23. Date

25. Address

27. City

28. State

29. Zip Code

31. Telephone (home)

32. Telephone (work)

34. Please explain your relationship with the individual(s) indicated above:

36. Name of agency and department or program that discriminated:

38. Agency or department name:

40. Name of individual (if known)

42. Address

44. City

45. State

46. Zip Code

48. Date(s) of alleged discrimination:

    Date(s) of alleged discrimination:

50. Date discrimination began

51. Last or most recent date

53. Alleged Discrimination

55. If your complaint is in regard to discrimination in the delivery of services or discrimination that involved the treatment of you by others by the agency or department indicated above, please indicate below the basis on which you believe these discriminatory actions were taken.

    1. Race
    2. Color
    3. Age

    1. Disability
    2. Religion
    3. National Origin

    1. Sex
    2. Income
    3. Retaliation

57. Explain: Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and other involved in the alleged discrimination.

59. Electronic Signature

60. Date

62. NOTE
    The City of Battle Creek prohibits retaliation or intimidation against anyone because that individual has either taken action or participated in action to secure rights protected by policies of the City. Please inform Ted Dearing listed above if you feel you were intimidated or experience perceived retaliation to filing this complaint.

    The City of Battle Creek prohibits retaliation or intimidation against anyone because that individual has either taken action or participated in action to secure rights protected by policies of the City. Please inform Ted Dearing listed above if you feel you were intimidated or experience perceived retaliation to filing this complaint.

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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit

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