Discrimination Complaint Form printable pdf download

Non Discrimination Complaint Procedures

These procedures provide guidance for all complaints filed under Title VI of the Civil Rights Act of 1964,

Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990 (ADA) as

they relate to any program or activity that is administered by Town of Florence including consultants,

contractors and vendors. Intimidation or retaliation as a result of a complaint is prohibited by law. In

addition to these procedures, complainants reserve the right to file a formal complaint with other State

or Federal agencies or to seek private counsel for complaints alleging discrimination. Every effort will be

made to resolve complaints at the lowest possible level.

(1) Any person who believes he and/or she has been discriminated against on the basis of race,

color, national origin, or disability may file a Title VI complaint by completing and submitting the

agency’s Title VI Complaint Form.

(2) Formal complaints must be filed within 180 calendar days of the last date of the alleged act of

discrimination or the date when the alleged discrimination became known to the

complainant(s), or where there has been a continuing course of conduct, the date on which the

conduct was discontinued or the latest instance of the conduct.

(3) Complaints must be in writing and signed by the complainant(s) and must include the

complainant(s) name, address and phone number. The Title VI contact person will assist the

complainant with documenting the issues if necessary.

(4) Allegations received by fax or e-mail will be acknowledged and processed, once the identity of

the complainant(s) and the intent to proceed with the complaint have been established. For

this, the complainant is required to mail a signed, original copy of the fax or email transmittal for

the complaint to be processed.

(5) Allegations received by telephone will be reduced to writing and provided to the complainant

for confirmation or revision before processing. A complaint form will be forwarded to the

complainant for him/her to complete, sign and return for processing.

(6) Once submitted Town of Florence will review the complaint form to determine jurisdiction. All

complaints will receive an acknowledgement letter informing her/him whether the complaint

will be investigated by the Town of Florence or submitted to the State or Federal authority for

guidance.

(7) Town of Florence will notify the ADOT Civil Rights Office of ALL Title VI complaints within 72

hours via telephone at 602-712-8946 ; email at civilrightsoffice@azdot.gov.

Discrimination Complaint Form