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DOUGLAS COUNTY 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." Note: 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: Mr. Frederick Perry, Title VI Coordinator/Director of Human Resources, Douglas County, 8700 Hospital Drive, Douglasville, GA 30134 1. Complainant's Name 2. Address 3. City, State and Zip Code 4. Telephone Number (home) 5. Person discriminated against (if someone other than the complainant) Name Address City, State and 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 c. Other 7. What date did the alleged discrimination take place? 8. 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. ---PAGE BREAK--- 9. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court? Yes No 10. Please provide information about a contact person at the agency/court where the complaint was filed. Name Address City, State and Zip Code Telephone Number 11. Please sign below. You may attach any written materials or other information that you think is relevant to your complaint. Complainant's Signature Date