Please complete all required fields!
If you answered "Yes" to this question please skip to question 5.
2. Please supply the name and relationship of the person for whom you are complaining.
3. Please explain why you have filed for a third party?
4. Please confirm that you have obtained the permission of the complainant if you are filing on behalf of a third party.
5. I believe the discrimination I experienced was based on (Check all that apply):
6. Date of alleged discrimination (Month, Day, Year).
7. Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.
8. May we release your identity and a copy of your complaint to the entity against whom you are complaining? Note: We may be unable to investigate your allegations without permission to release your identity and complaint.
9. Have you previously filed a Title VI complaint with CDTC?
10. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court?
11. Please provide information about a contact person at the agency / court where the complaint was filed.