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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.