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V. Title VI Complaint Form Please complete this form to the best of your ability. If you need translation or other assistance, contact Rachel Hamer, Administrative Services Manager, Town of Minden. Phone: Email: Basis of Complaint (circle all that apply): Race Color National Origin Who discriminated against you? Name of How were you discriminated against? (Attach additional pages if more space is needed) Where did the discrimination occur? ---PAGE BREAK--- Dates and times discrimination occurred? Were there any other witnesses to the discrimination? Name Organization/Title Work Telephone Home Telephone How would you like to see this situation resolved? Have you filed your complaint, grievance, or lawsuit with any other agency or court? Who When Status (pending, resolved, etc.) Result, if known Complaint number, if known Do you have an attorney in this matter?