Address:
Telephone (Home):
Telephone (Work):
Electronic Mail Address:

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 and relationship of the person for whom you are complaining:
 
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 behalf of a third party.
Yes
No

Section III:
I believe the discrimination I experienced was based on (check all that apply):
[ ] Race                                 [ ] Color                                              [ ] National Origin                        [ ] Age
[ ] Disability                         [ ] Family or Religious Status            [ ] Other (explain) ____________________________
Date of Alleged Discrimination (Month, Day, Year):    __________
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of 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:
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:
The Arc of Indian River County, Inc.
1375 16th Avenue, Vero Beach, FL 32960
 
If information is needed in another language, contact 772-562-6854.