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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 Village of Nashville 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.


If you need assistance completing this form, please contact Cathy Lentz by phone at 517-852-9544 or via e-mail at clerknashville@yahoo.com.


Name: _________________________________________      Date: _______________________


Street Address: _________________________________________________________________


City: ______________________________     State: ____________________     Zip: _________


Telephone: _________________________ (home)      ____________________________ (work)


Individual(s) discriminated against, if different than above (use additional pages, if needed).


Name: __________________________________________     Date: ______________________


Street Address: _________________________________________________________________


City: ______________________________     State: ____________________      Zip: _________


Telephone: __________________________ (home)     ___________________________ (work)


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


Name of agency and department or program that discriminated:


Agency or department name: ______________________________________________________


Name of individual (if known): ____________________________________________________


Address: ______________________________________________________________________


City: _____________________________     State: _____________________    Zip: __________


Date(s) of alleged discrimination:

Date discrimination began ______________________   Last or most recent date _____________




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.


____ Race


____ Color


____ Age


____ Disability


____ Religion


____ National Origin


____ Sex


____ Income


____ Retaliation


Explain:  Please explain as clearly as possible what happened.  Provide the name(s) of witness(es) and others involved in the alleged discrimination.  (Attach additional sheets, if necessary, and provide a copy of written material pertaining to your case).
















Signature: ______________________________________     Date: _______________________


Please return completed form to: Cathy Lentz, Village Clerk, 203 N. Main Street, P.O. Box 587, Nashville, MI  49073; Phone: 517-852-9544; Fax: 517-852-0331; E-mail: clerknashville@yahoo.com.


Note:  The Village of Nashville 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 Village.  Please inform the person listed above if you feel you were intimidated or experience perceived retaliation in relation

               Complainant Signature                                                     Date