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SALEM SKIPPER TITLE VI COMPLAINT FORM Section I Name: Address: Telephone (Home): Telephone (Work): Electronic Mail Address: Do you have Accessible Format Requirements? Yes [ ] No [ ] If yes, what are they: Large Print [ ] Audio Tape [ ] TDD [ ] Other [ ] If other, please list: 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 of and your relationship to the person for whom you are filing this 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 their behalf. Yes [ ] No [ ] Section III I believe the discrimination I experienced was based on (check all that apply): [ ] Race [ ] Color [ ] National Origin Date of Alleged Discrimination (Month, Day, Year): Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all person(s) who were involved. Include the name and contact information of ---PAGE BREAK--- the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please use the back of this form. Section IV Have you previously filed a Title VI complaint with this agency? Yes [ ] No [ ] Section V Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? [ ] Yes [ ] No If yes, check all that apply: [ ] Federal Agency [ ] Federal Court [ ] State Agency [ ] State Court [ ] Local Agency Please provide information about a contact person at the agency/court where the complaint was filed. Name: Title: Agency: Address: Telephone: ---PAGE BREAK--- Section VI Name of agency complaint is against: Contact person: Title: Telephone number: You may attach any written materials or other information that you think is relevant to your complaint. Signature and date required below: Signature Date Please submit this form in person at the address below or mail this form to: City of Salem Legal Department, 93 Washington St., Salem, MA 01970.