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Title VI Civil Rights Complaint Form The following information is necessary to assist us in processing your complaint. If information is needed in another language, please contact (661) 267-5115. Complete and return this form to: City of Palmdale, 38300 Sierra Highway, Palmdale, CA 93550. 1. Complainant’s Name: 2. Address: 3. City: State: Zip Code: 4. Telephone Number (home): (business): 5. Person discriminated against (if someone other than the Complainant): Name: Address: City: State: Zip Code: 6. Which of the following best describes the reason you believe the discrimination took place? Was it because of your: a. Race b. Color c. National Origin 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. 9. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court? Yes: No: ---PAGE BREAK--- If yes, check each box that applies: Federal agency Federal court State agency State court Local agency 10. Please provide information about a contact person at the agency/court where the complaint was filed. Name: Address: City: State: Zip Code: 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