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Cayuga County Title VI 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 grounds 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." If you feel you have been discriminated against by Cayuga County, please provide the following information in order to assist us in processing your complaint and send it to: Cayuga County Offices County Administrator’s Office 160 Genesee Street, Floor 2 Auburn, NY 13021 If you have questions about how to prepare a Title VI Complaint Form, you may contact the County Administrator’s Office at (315) 253-1525. More information about "How to File a Title VI Complaint" may be found on Cayuga County’s website at www.cayugacounty.us. Important: We cannot accept your complaint without a signature, so please sign and date on the last page of the form. Section I Telephone Numbers: (Home) (Work) Accessible Format Requirements? Large Print Audio tape ---PAGE BREAK--- Cayuga County Title VI Complaint Form 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 Ill What is the Basis of the Complaint? Please check all that may be applicable: Race O Color O Gender O National Origin O Age O Disability (ADA) O Low-Income O Limited English Proficiency O Section IV Who allegedly discriminated against you? Name of Person or Agency: Title: Address: Telephone Numbers: (Home) (Work) Section V How were you discriminated against? Where did the alleged discrimination occur? ---PAGE BREAK--- Cayuga County Title VI Complaint Form Date(s) and time(s) discrimination occurred? First Time: Second Time: Third Time: Were there any witnesses to the alleged discrimination? Name Title Work Home What can Cayuga County do to resolve the complaint? Have you filed your complaint with any other Federal, State or local agencies? Person or Agency Name: Date: Complaint Number (if known): Please Sign Here: Date: [Note – Cayuga County cannot accept your complaint without a signature.]