ADA / Title VI / Non-Discrimination Complaint Form

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ADA / Title VI / Non-Discrimination Complaint Form

Complaintant Information

* Full Name:

* Home Address:

* City:

* State:

* Zip Code:

* Email Address:

* Best Daytime Phone Number:

Additional Phone Number:

Complaint Information

* In what way do you believe you were discriminated against? (check all that apply)
Race
Color
National Origin
Sex / Gender
Age
Religion
Disability
Family Status
Marital Status
Sexual Orientation
Gender Identity or Expression
Other

In what other way do you believe you were discriminated against that is not listed above:

* Date of alleged discriminatory incident:

* City department where alleged incident occurred:

* Name(s) of City employee(s) involved, if known:

* Please explain as clearly as possible what happened and how you experienced discrimination or were denied access or accommodation. Indicate who was involved and include the names and contact information of any witnesses. If the incident took place on a StarMetro bus, please provide identifying information (bus number, route, direction you were traveling, etc.) if you are able to do so:

* Have 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
State agency
Local agency
Federal Court
State Court

Please provide information about the agency/court where the complaint was filed:

* Agency/courtname:

* Agency/court contact's name:

* Agency/court contact's address:

* City:

* State:

* Zip Code:

* Phone Number:

You may attach written materials, photographs, or other documentation that you believe is relevant to your complaint.

Optional Upload #1:

Optional Upload #2:

* For security, please verify you are a real person.

* Agreement

By checking this box, I acknowledge that I have read and agree to the terms of this form and the Talgov.com Privacy Policy. I understand that this electronic acknowledgement is legally binding and has the same effect as my handwritten signature.

Contact Info
City Hall
300 S. Adams St.
Tallahassee FL 32301
850-891-0000
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John E. Dailey, Mayor
Jeremy Matlow
Jacqueline "Jack" Porter
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City Hall
300 S. Adams St.
Tallahassee FL 32301
850-891-0000
Maps and Directions
Contact Us
Directory/Site Map
Privacy Policy | Disclaimer | Translate This Site

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