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Title VI/LEP Plan March, 2015 Page 12 TITLE VI PROGRAM AND RELATED STATUTES DISCRIMINATION COMPLAINT AGAINST GORDON COUNTY Name: Telephone (home): Telephone (work): Address: City, State, Zip Code: Name of COUNTY Staff Person that You Believe Discriminated Against You: Address: City, State, Zip Code: Date of Alleged Incident: You were discriminated against because of: Race Retaliation Sex Familial Status Religion Color National Origin Age Disability Other (Language) Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also attach any written material pertaining to your case. Signature: Date: