Civil Rights Act – Title VI Complaint Form

The City of Kettering is committed to ensuring no person will be denied the benefits of, be excluded from participation in, or be subjected to discrimination under any program, service, or activity based on race, color, national origin, sex, age, disability, low-income status, or limited English proficiency. Title VI/Nondiscrimintion complaints must be filed within 180 calendar days from the date of the alleged discrimination.

Complainant Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Ae you filing this complaint on your own behalf?
- Yes
- No
If Yes, then Date of Past Incident
MM slash DD slash YYYY
Agency/Court Case Number
Date Filed
MM slash DD slash YYYY
Attorney Name and Contact Information
Date of Current Incident
MM slash DD slash YYYY
Select Discrimination
Provide the name and description of the city representative who is discriminating
Describe the incident
Provide witness names and contacts if applicable
What has been done to try and resolve this complaint?
What is the desired outcome of this complaint
Name (person who filled out the form)
First Last
Date (form filled out)
MM slash DD slash YYYY