Title VI

2. First Name
3. Last Name
5. Address1
7. Address2
9. City
10. State
11. Zip
13. Please indicate the basis of your complaint:

    1. Race
    2. Color
    3. National Origin
    4. Other Class
14. Date and place of alleged discriminatory action(s).

    Please include the earliest date of discrimination and the most recent date of discrimination.

16. How were you discriminated against?

    Describe the nature of the action, decision, or conditions of the alleged discrimination. Explain as clearly as possible what happened and why you believe your protected status (basis) was a factor in the discrimination. Include how other persons were treated differently from you. (Attach additional pages, if necessary).

18. If you feel that you have been retaliated against. separate from the discrimination alleged above, please explain the circumstances below.

    Explain what action you took which you believe was the cause for the alleged retaliation.

20. Names of individuals responsible for the discriminatory action(s):
22. Names of persons (witnesses, fellow employees, supervisors, or others) whom we may contact for additional information to support or clarify your complaint (attach additional pages, if necessary):
24. Name
25. Address
26. Phone Number
28. Name
29. Address
30. Phone Number
32. Name
33. Address
34. Phone Number
36. Have you filed or intend to file, a complaint regarding the matter raised with any of the following?
38. If yes, please provide the filing dates.

    1. U.S. Department of Transportation
    2. Federal Highway Administration
    3. Federal Transit Administration
    4. Office of Federal Contract Compliance Programs
    5. Texas Department of Transportation
    6. U.S. Equal Employment Opportunity Commission
    7. U.S. Department of Justice

    Check all that apply.

39. Date Filed:

    Please list all filing dates with corresponding agency.

41. Have you discussed the complaint with any City of Kennedale representative?
43. If yes, provide the name, position and date of discussion.
45. Briefly explain what remedy, or action, you are seeking for the alleged discrimination.
47. Please provide any additional information and/or photographs, if applicable, that you believe will assist with an investigation.
49. By entering your first and last name below, you are providing your electronic signature, affirming that the information you have provided is true and accurate to the best of your knowledge. This serves as your official signature in accordance with the requirements of Title VI of the Civil Rights Act of 1964 and applicable state and federal regulations.
51. Signature*

    Please type your first and last name.

52. Date*
    Date
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field