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VILLAGE OF NASHVILLE

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 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 _____________

 

ALLEGED DISCRIMINATION:

 

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).


 


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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