Complaint Form

Title VI Complaint Form

Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”

The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please let us know.

Complete and return this form to:

City of Rio Vista
Delta Breeze
1 Main Street
Rio Vista, CA 94571

Email to: rvdb@transportation-concepts.com

  1. Complainant’s Name:_____________________________________
     
  2. Address:_______________________________________________
     
  3. City:____________________ State:_________Zip Code:________
     
  4. Telephone Number (home):____________ (business):___________
     
  5. Person discriminated against (if someone other than the complainant):_____________________________________________        Name: ______________________________________________    Address:____________________________________________        City:______________ State:_________ Zip Code:___________
     
  6. Which of the following best describes the reason you believe the discrimination took place? Was it because of your: 
    a. Race/Color: __________

           b. National Origin: _______
 

  1. What date did the alleged discrimination take place?____________
     
  2. In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible. Please use the back of this form if additional space is required.

________________________________________________________________ ________________________________________________________________ ________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

  1. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court? Yes :_______ No:_______

      If yes, check each box that applies:____________________________

           Federal agency: _______ 

           Federal court: ________ 

           State agency: ________

           State court: __________

           Local  agency: _________

  1. Please provide information about a contact person at the agency/court where the complaint was filed.

Name: ______________________________________________________

Address:_____________________________________________________ City:______________ State:________ Zip Code:_____________________

Telephone Number:____________________________________________

  1. Please sign below. You may attach any written materials or other information that you think is relevant to your complaint.


___________________________                    _________________
Complainant’s Signature                                Date

If you have any questions or need assistance filling out this form, please contact:

Tony Cabral, Site Manager Delta Breeze
City of Rio Vista
One Main Street, Rio Vista, CA 94571
(707) 330-6063,

TTD/TTY users can call 711 through the California Relay Service.

The City will respond within 60 days of the alleged discrimination once the City receives this form.  The complaint must be filed within 180 days of the date of the alleged discrimination.