TITLE VI COMPLAINT FORM
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 firstname.lastname@example.org.
Street Address: _________________________________________________________________
City: ______________________________ State: ____________________ Zip:
Telephone: _________________________ (home)
against, if different than above (use additional pages, if needed).
Name: __________________________________________ Date: ______________________
City: ______________________________ State: ____________________
Telephone: __________________________ (home) ___________________________ (work)
Please explain your relationship with the individual(s) indicated above: ____________________
Name of agency and department or program that discriminated:
or department name: ______________________________________________________
individual (if known): ____________________________________________________
City: _____________________________ State: _____________________
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.