Discrimination Complaint Form Page 4
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4Have 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:
Name of person complaint is against:
Title:
Location:
Telephone Number (if available):
You may attach any written materials or other information that you think is relevant to your
complaint. Your signature and date are required below
Signature
Date
Please submit this form in person at the address below, or mail this form to:
Town of Florence, Title VI Coordinator
775 North Main Street, P. O. Box 2670
Florence, Arizona 85132
520-868-7549
A copy of this form can be found online at
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