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CITY OF SANTA ANA <br />TITLE VI COMPLAINT FORM <br />Please confirm that you have obtained the permission of the aggrieved party if you are filing on <br />behalf of a third party. Yes No <br />SECTION III <br />List type of discrimination you experienced: (please check all that apply): <br />Race ( ) Color ( ) National Origin ( ) Other <br />Please indicate your race/color, if it is a basis of your complaint <br />Please describe your national origin, if it is a basis of your complaint <br />Location where alleged discrimination occurred <br />Time and date of alleged discrimination <br />Name/Position title of the person who allegedly subjected you to Title VI discrimination: <br />Please explain as clearly as possible what happened, why you believe it happened and how you <br />were discriminated against. You should include specific details and any other information that <br />would. assist us in our investigation of your allegations. Please also provide any other <br />documentation that is relevant to this complaint. (Use a separate sheet if necessary) <br />Please list below any persons, witnesses, if known, whom we may contact, for additional <br />information to support or clarify your complaint (Name, Address and Telephone Number): <br />Have you previously filed a Title VI complaint with this agency? Yes No <br />Have you filed this complaint with any other Federal, State, or local agency, or with any Federal. <br />of State court? Yes No <br />Federal Agency: Date: <br />Federal Court:- Date: <br />State Agency: Date: <br />State Court: Date: <br />Local Agency: Date: <br />55C-13 <br />7 <br />