Central Arkansas Development Council Title Vi/ada Complaint Form printable pdf download

Central Arkansas Development Council

TITLE VI/ADA Complaint Form

Title VI of the Civil Rights Act of 1964 states "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." Title II of the

Americans with Disability Act (ADA) provides that, “No qualified individual with a disability shall, by

reason of such disability, be excluded from participation in or be denied the benefits of the services,

programs, or activities of a public entity, or be subjected to discrimination by any such entity.”

Title 42 U.S.C. Sections 2000d & 12131

Please provide the following information necessary in order to process your complaint. A formal

complaint must be filed within 180 days of the occurrence of the alleged discriminatory act. Assistance is

available upon request. Please contact CADC Human Resource Manager at (501) 315-1121.

Complete this form and return to:

Central Arkansas Development Council

Attn: Human Resource Manager

P. O. Box 580

Benton, AR 72018

Complainant's Name: ________________________________________________________________________________________________

Address: _____________________________________________________

City: ________________________________________________

State: _________________________________________________________

Zip Code: __________________________________________

Telephone (Home): _________________________________________

Telephone (Work): _______________________________

Person(s) discriminated against (if other than complainant)

Name: _________________________________________________________________________________________________________________

Address: _____________________________________________________

City: ________________________________________________

State: _________________________________________________________

Zip Code: __________________________________________

Telephone (Home): __________________________________________

Telephone (Work): ______________________________

What is the discrimination based on?

Race/Color

Disability

National Origin

Religion

Sex

Other: ____________________________

Date of the alleged discrimination: _________________________

Location: __________________________________________

Central Arkansas Development Council Title Vi/ada Complaint Form