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2. Complaint of Title VI discrimination against the City of Issaquah, Washington
4. Complainant Contact Information
6. First Name*
7. Last Name*
9. Street Address*
10. Apt #
12. City*
13. State*
14. Zip*
16. Phone*
17. Email Address*
19. Mailing Address (If Different)
20. Apt #
22. City
23. State
24. Zip
26. If you are an inmate at a correctional facility, provide your inmate number
30. Aggrieved party contact information (if different from complainant):
32. First Name
33. Last Name
35. Street Address
36. Apt #
38. City
39. State
40. Zip
42. Phone
43. Email Address
47. Statement of Complaint – Include all facts upon which the complaint is based.*
48. Upload a file if needed
50. Date of Incident
51. Department or agency (if known)
53. Address/location (if known)
55. I believe the above actions were taken because of my:*

    1. Race
    2. Color
    3. National Origin

    1. Religion
    2. Sex
    3. Other
57. Name, position, and department of City employees you have contacted regarding the incident(s).
59. Witnesses or other involved – provide name, address, telephone number(s) and e-mail (if available).
60. Upload a file if needed
62. If you have filed a grievance, complaint or lawsuit regarding this matter anywhere else, give name and address of each place where you have filed.
63. Upload a file if needed
65. Explain any actions the recipient has taken or proposed to resolve the issue.
67. In the complainant’s view, what would be the best way to resolve the grievance?
71. I affirm that the foregoing information is true to the best of my knowledge and belief. I understand that all information becomes a matter of public record after the filing of this complaint.*

    1. I affirm
73. Complainant*
74. Date*
    Date
76. Aggrieved Party
77. Date
    Date
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field