Title VI Complaint Form (Spanish)

Title VI Complaint Form
Title VI of the Civil Rights Act of 1964 states "No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance including subrecipients."

If you believe that you have been discriminated against because of your race, color, or national origin (including limited English proficiency), by agency programs or activities, you have the right to file a formal complaint with WSDOT within 180 days of the alleged incident by completing the form below.

Complaints may be submitted via mail, email, or in person to:

Title VI Coordinator
City of Sammamish
TitleVICoordinator@sammamish.us

425-295-0500

Mailing address:
801 228th Avenue SE
Sammamish, WA 98075-9509

Physical Address:
801 228th Avenue SE
Sammamish, WA 98075-9509
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Best time of day for phone call

8 a.m - 10 a.m10 a.m. - 12 p.m.12 p.m. - 2 p.m.2 p.m. - 4 p.m.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the alleged discrimination based on? Select all that apply.

RaceColorNational origin (including limited English proficientcy)
Date of alleged incident

MonthDayYear
Date
Agency or person(s) responsible for the alleged discrimination
Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Describe the alleged discrimination. Please explain what happened, why you believe it happened and how you were discriminated against. Indicate who was involved. Be sure to include how you feel other persons were treated differently than you.
What remedy are you seeking for the alleged discrimination? Please note that this process will not result in the payment of punitive damages or financial compensation.
List any other persons that we should contact for additional information in support of your complaint. Please include contact information including email address, phone number and mailing address.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Information
List any other agencies with whom you have filed this same complaint.
Please provide contact person information at the agency / court where the complaint was filed.
Agency Name
State / Province
Additional Information
Please verify that you are human*
Should be Empty:

Title VI Complaint Form

Agency or person(s) responsible for the alleged discrimination