Central Arkansas Development Council Title Vi/ada Complaint Form Page 2

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Agency or person that was responsible for the alleged discrimination: ________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Have you filed this complaint with any other Federal, State, or local agency? If so, whom? ___________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
What remedy are you seeking? _____________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
List names and contact information of persons who may have knowledge of the alleged discrimination.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Describe the alleged discrimination. Explain what happened and whom you believe as responsible.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Please sign and date. The complaint will not be accepted if it has not been signed. You may
attach any written materials or other supporting information you think is relevant to your
complaint.
_____________________________________________
________________________
Signature
Date
Title VI/ADA Complaint form updated 05/18/16

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