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Complaint of Title VI Discrimination
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Complaint of Title VI discrimination against the City of Issaquah, Washington
Complainant Contact Information
First Name
*
Last Name
*
Street Address
*
Apt #
City
*
State
*
Zip
*
Phone
*
Email Address
*
Mailing Address (If Different)
Apt #
City
State
Zip
If you are an inmate at a correctional facility, provide your inmate number
Aggrieved party contact information (if different from complainant):
First Name
Last Name
Street Address
Apt #
City
State
Zip
Phone
Email Address
Statement of Complaint – Include all facts upon which the complaint is based.
*
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Date of Incident
Department or agency (if known)
Address/location (if known)
I believe the above actions were taken because of my:
*
Race
Color
National Origin
Religion
Sex
Other
Name, position, and department of City employees you have contacted regarding the incident(s).
Witnesses or other involved – provide name, address, telephone number(s) and e-mail (if available).
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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.
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Explain any actions the recipient has taken or proposed to resolve the issue.
In the complainant’s view, what would be the best way to resolve the grievance?
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.
*
I affirm
Complainant
*
Date
*
Date
Aggrieved Party
Date
Date
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