[Washoe County] Title VI Complaint Form

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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."

Please provide the following information to process your complaint. Assistance is available upon request by contacting the Civil Rights Office of Washoe County. Complete this form and email, US mail or deliver in person to:

Washoe County
Human Resources – Title VI
1001 E. Ninth Street, Room A220, Reno, NV 89521
Coordinator:
Elizabeth Jourdin, equity@washoecounty.gov
775-328-2801

Home Phone:

Cell Phone:

Is the person discriminated against the same person as the complainant?

Yes

Home Phone of Person Discriminated Against:

Cell Phone of Person Discriminated Against:

What was the discrimination based on? (Check all that apply):

Race

Color

National Origin

Date of incident resulting in discrimination:

Describe how you were discriminated against, including details of the incident, location, persons involved.

Did you file this complaint with another federal, state or local agency, or with a federal or state court? (Check the appropriate space):

Yes

If your answer is yes, check each agency that a complaint was filed with:

Federal Agency

Federal Court

State Agency

State Court

Local Agency

Provide the contact person information for the agency you also filed the complaint with:

Name of Agency:

Date Filed:

Sign below prior to submitting form. Please attach any supporting documents or information that can be helpful in evaluating your claim.

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Upload file(s), if applicable.

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