Title VI / Nondiscrimination

Title VI Complaint Form

MVMPO Title VI Discrimination Complaint Form

Please provide the following information in order for us to process your complaint. This form is available in alternate formats and multiple languages. Should you require these services or any other assistance in completing this form, please let us know.

 

Name:________________________________________________________________

Address:______________________________________________________________

Telephone Numbers: (Home)____________(Work)____________(Cell)____________

Email Address:_________________________________________________________

 

Please indicate the nature of the alleged discrimination:

Categories protected under Title VI of the Civil Rights Act of 1964:

☐ Race   ☐ Color   ☐ National Origin (including limited English Proficiency)

Additional categories protected under related Federal and/or State laws/orders:

☐ Disability   ☐ Age   ☐ Sex   ☐Sexual Orientation   ☐Religion ☐Ancestry

☐Gender   ☐Ethnicity   ☐Gender Identity   ☐Gender Expression   ☐Creed   ☐Veteran’s Status   ☐Background

 

Who do you allege was the victim of discrimination?

☐You   ☐A Third Party Individual   ☐A Class of Persons

 

Name of individual and/or organization you allege is discriminating:

___________________________________________________________

 

Do you consent to the investigator sharing your name and other personal information with other parties to this matter when doing so will assist in investigating and resolving your complaint?

☐Yes   ☐No

Please describe your complaint. You should include specific details such as names, dates, times, witnesses, and any other information that would assist us in our investigation of your allegations. Please include any other documentation that is relevant to this complaint. You may attach additional pages to explain your complaint.

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Have you filed this complaint with any other agency (Federal, State, or Local)?

☐Yes   ☐No

If yes, please identify:____________________________________________________

 

Have you filed a lawsuit regarding this complaint?

☐Yes   ☐No

If yes, please provide a copy of the complaint.

 

 

 

 

Signature: ____________________________________ Date:___________________

 

 

Mail to:      Title VI Coordinator, Merrimack Valley Planning Commission, 160 Main Street, Haverhill, MA 01830

Email to:    akomornick@ mvpc.org

MVPC

We've been around for over 50 years, governed by a simple vision: plan, develop and promote sustainable development of Merrimack Valley by efficient use of regional resources.



  • Merrimack Valley Planning Commission
    160 Main Street
    Haverhill, MA 01830
    p: 978.374.0519
    f: 978.372.4890
    e: info@mvpc.org


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