TITLE VI COMPLAINT FORM
LEP/LAP COMPLAINT FORM

Section I:
Name:
Address:
Telephone (Home):	Telephone (Work):
Electronic Mail Address:
Accessible Format Requirements?	Large Print	Audio Tape
TDD	Other
Section II:
Are you filing this complaint on your own behalf?	Yes*	No*
*If you answered “yes” to this question, go to Section III.
If not, please supply the name and relationship of the person for whom you are complaining:
Please explain why you have filed for a third party:
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.	Yes	No
Section II:
I believe the discrimination I experienced was based on (check all that apply) [ ] Race [ ] Color [ ] National Origin [ ] Limited English Proficiency
Date of Alleged Discrimination (Month, Day, Year): ____________________ Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please use the back of this form
Section IV:
Have you previously filed a Title VI complaint with this agency?	Yes	No
Section V:
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 all that apply:
[ ] Federal Agency
[ ] Federal Court	[ ] State Agency
[ ] State Court	[ ] Local Agency
Please provide information about a contact person at the agency/court where the complaint was filed.
Name:
Title:
Agency:
Address:
Telephone:
Section VI:
Name of agency complaint is against:
Contact person:
Title:
Telephone number:

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

Signature and date required below

Signature	Date

Please submit this form in person at the address below, or mail this form to:

CCNRC Family of Care10200 La Plata Road

La Plata, MD 20646