Title VI Civil Rights Discrimination Claim Form

Pursuant to Chapter 4.92 RCW, this form is for filing a tort claim against the City of Mukilteo, Washington. Some of the information requested on this form is required by RCW 4.92.100 and may be subject to public disclosure. Please attach up to three documents related to injuries, losses, repairs or other expenses relevant to this claim. Refer to the City of Mukilteo's Civil Rights and Title VI Complaint Procedures.

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 may file a formal complaint. Complete the complaint form below, answering every question. Upon receipt of the complaint form, it will be reviewed to ensure that it is complete. A notice acknowledging receipt will be provided within 10 working days. These procedures do not deny you the right to file a formal complaint directly with WSDOT or federal funding agencies. You may seek private counsel for complaints alleging discrimination. Federal law prohibits intimidation or retaliation against you of any kind.

Title VI Civil Rights Discrimination Claim Form

Steps

1. Claimant Information(current) This section is complete This section is incomplete
2. Discrimination This section is complete This section is incomplete
3. Discrimination Incident This section is complete This section is incomplete

Claimant Information

Date of Claim Form Submission *
Date of Claim Form Submission
Name*
Please describe your relationship to the person making this Title VI discrimination claim. *
Address
City
State
Zip Code
Phone Number*
Email Address*
Best time of day to contact you about this complaint:
1. 7 am to 10 am
2. 10 am to 1 pm
3. 1 pm to 4 pm
4. 4 pm to 7 pm
5. Other
If Other, Please Specify
Name
Provide the name of the individual aggrieved or claiming discrimination if someone other than the person completing this form.
Address
City
State
Zip Code
Phone Number
Please provide us with the phone number of the person who is making a discrimination claim.
Email Address*
Please provide the email address of the person who is making a discrimination claim.
Do you or the person making this discrimination claim require language interpretation or sign language? *
1. Yes
2. No
Tell us if the person completing this form or the person who is making this discrimination claim requires the City of Mukilteo to provide a complaint form in a different language or in sign language.
What language do you need this form translated into? If you would like a sign interpreter, type "sign."
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Discrimination

I believe I have been discriminated against in: *
I believe I have been discriminated against because of my: *
If Other, Please Specify
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Discrimination Incident

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. If you have any other information about what happened, please attach supporting documents to this form.*
Please upload any written materials or additional information you believe is relevant to this complaint:
Accepted file types: JPG, GIF, PNG, PDF, Max. file size: 250 MB, Max. files: 3.
We accept only.GIF, JPG,.PDF or.PNG documents.
Please provide the name, address and telephone number of person(s) who is alleged to have discriminated against you:*
Please provide the date, time and place where the discrimination occurred:*
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 their names, addresses, phone numbers, email addresses, etc.
List any other agencies with whom you have filed this same complaint:
If none, type N/A.
Consent
1. I declare under penalty of perjury under the laws of the State of Washington the foregoing is true and correct.

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Title VI Civil Rights Discrimination Claim Form