Title VI Complaint Form (PDF)

Town of Waterford 
TITLE VI DISCRIMINATION COMPLAINT FORM 
 
Complainant’s Name: 
 
Street Address: 
 
City/State/Zip: 
 
Phone: 
 
Discrimination because of: Race____ Color____ National Origin ____ Sex____ 
Age____  Disability____  Creed____   Other____ 
 
Please provide the date(s) and location of the alleged discrimination, the name(s) of the 
individual(s) who allegedly discriminated against you including their titles (if known). 
 
 
 
 
 
 
Please provide the names, addresses and telephone numbers of any witnesses. 
 
 
 
 
 
 
Explain as briefly and as clearly as possible what happened, how you feel that you were 
discriminated against and who was involved. Please include how other persons were 
treated differently from you. 
 
 
 
 
 
 
Signature: 
 
Date: 
 
You may use additional sheets of paper. Also include any written materials pertaining to your complaint. 
Title VI comp form