Title VI Complaint Form Regarding a City of Greeley Service, Program or Activity

Title VI of the Civil Rights Act of 1964 requires that “no person in the United States shall, on the ground of race, color or 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 the City in processing a complaint. If any person interested in filing a complaint needs assistance, including sign language assistance, documents in Braille or other ways of making information and communications accessible, please contact the City’s Title VI Coordinator Monday – Friday, 8 a.m. – 5 p.m. via email at [email protected] or by calling 970-573-9455.

Submit a Title VI Complaint

Complainant’s Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Home/Cell Phone Number(Required)

Business Phone

Person Discriminated Against (if someone other than Complainant)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home/Cell Phone Number

Business Phone

City of Greeley Agency, Facility, Department, or Program Complaint is About

Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location details (i.e. front desk, outside, north door)

Please provide as much information about the location as possible.

Date of Incident Resulting in Complaint

In your own words, describe the circumstances leading to this complaint.(Required)

What happened and who was responsible? If possible, provide names of the individuals involved.

Were there any witnesses to the incident? If yes, please provide as much information as possible about any witness or witnesses.

Witness Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home/Cell Phone Number

Business Phone Number

Witness Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home/Cell Phone Number

Business Phone Number

Have any efforts been made to file or resolve this complaint through the internal grievance procedure of any City of Greeley department?

Yes

If yes, what is the status of the grievance?

Have you filed a complaint about this same incident with any other federal, state or local governmental agency or with a federal or state court? Please check any that apply.

Other Agency Contacted

Federal Agency

Federal Court

State Agency

State Court

Local Agency

Provide the name of the agency or agencies with whom you have filed a complaint.

Please provide the contact information of the person with the agency/court that you provided above.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Date Filed

Attach any documents you believe support your complaint.

Max. file size: 400 MB.

CAPTCHA