Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the grounds of race, color, and national origin be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” The following information is necessary to assist us in processing your complaint. If you need assistance in completing the form, please contact the Title VI Coordinator: Title VI Coordinator City of Riverside 3900 Main Street, 2nd Floor Riverside, CA 92522 Ph: (951) 351-6162 / Fax: (951) 826-6320 TDD: TTY: 7-1-1 / Email: [email protected] Complainant’s Name Mailing Address City/State/Zip Code Phone Person discriminated against (if other than complainant) Name Address City/State/Zip Code Which of the following best describes the reason you believe the discrimination took place? Race Color National Origin In your own words, describe the alleged discrimination. Explain what happened and whom you believe to be responsible. Please use additional sheets of paper if necessary. What date did the alleged discrimination take place? List any others who may have knowledge of this event Name Address City/State/Zip 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 each box that applies Federal Agency Federal Court State Agency State Court Local Agency Please provide a contact name at the agency/court where the complaint was filed Full Name * Date * CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
