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 ADATitleVIcoordinator@greeleygov.com or by calling 970-336-4029.

Submit a Title VI Complaint

Complainant’s Name
Address

Person Discriminated Against (if someone other than Complainant)

Name
Address

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

Address
Please provide as much information about the location as possible.
MM slash DD slash YYYY
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
Address
Witness Name
Address
Have any efforts been made to file or resolve this complaint through the internal grievance procedure of any City of Greeley department?

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

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

Name
Address
MM slash DD slash YYYY
Max. file size: 64 MB.