Title VI Complaint Form

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TOWN OF WATERFORD 
TITLE VI DISCRIMINATION COMPLAINT FORM 
It is the policy of the Town of Waterford to abide by Title VI of the Civil Rights Act of 1964 and related non-discrimination authorities, 
which provides in part that:  No person in the United States shall, on the grounds of race, color, national origin, sex, age, disability, income 
level or Limited English Proficiency be excluded from participation in, be denied the benefits of, or otherwise be subjected to 
discrimination under any program or activity receiving Federal financial assistance.  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 the 180 days period, you have 
60 days after you became aware of the discrimination to file your complaint.  This form may be used to file a complaint with the Town of 
Waterford for alleged violations of Title VI of the Civil Rights Act of 1964.  
Complainant’s Name:  ________________________________________________________________________ 
Home Address:  __________________________________ Town:  _______________ State: ______  Zip: ______ 
Home Phone:  ____________________  Cell Phone:  ___________________  Work Phone: __________________ 
Email:  ________________________________________________  Race:  ______________   Sex:  ____________ 
Date alleged discrimination occurred:  _________________________________ 
Basis of Alleged Discrimination: 
☐Race
☐Color
☐National Origin
☐Sex
☐Age
☐Disability
☐Income Level
☐Limited English Proficiency
Describe the alleged discrimination with details and description of Town Department or individuals involved, 
including any potential witness information.  Please provide documentation, if any. (Use additional sheets if 
necessary): 

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Have you filed this Complaint with another Federal, State, or local agency or with a Federal or State Court? 
☐Yes
☐No
If yes, when and who did you file the complaint with: _______________________________________________ 
__________________________________________________________________________________________ 
Signature of Complainant:______________________________________________________________ 
Date:  ________________________________ 
Please return this complaint form to: 
Town of Waterford 
Dani Gorman, Human Services Administrator 
15 Rope Ferry Road 
Waterford, CT  06385 
Email:  dgorman@waterfordct.org 
SIGN