PREBLE COUNTY
COUNCIL ON AGING

Celebrating 44 Years of Service

1973 - 2017

Discrimination Complaint Form

Discrimination Complaint Form
Preble County Council on Aging, Inc.

 
Section I:
Name:
Address:
Telephone (Home): Telephone (Work):
Email Address:
Accessible Format Requirements?                              [  ] Large Print [  ]  Audio Tape
                                                                                                    [  ] TDD [  ]  Other
Section II:
Are you filing this complaint on your own behalf:               [  ]  Yes* [  ]  No
*If you answered "yes to this question, go to Section III.
If not, please supply the name and relationship of the person for whom you are complaining: 

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. [  ] Yes        [  ]  No
Section III:
I believe the discrimination I experienced was based on (Check all that apply):
[   ] Race                  [  ] Color                  [  ] National Origin     
[  ] Disability
Note: Title VI of the Civil Rights Act of 1964 protects people from discrimination based on race, color, and national origin. Note: The Americans with Disabilities Act of 1990 (ADA) protects people from discrimination based on disability.
Date of Alleged Discrimination (Date, Time and Location):    ___________________________
Explain as clearly as possible what happened and why you believe you were discriminated against.  Describe all persons who were involved.  Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.  Please include mobility aid used (if any), Vehicle number, any photographs or any information to illustrate the claim.  If more space is needed, please use the back of this form.

 

 

 

 

Section IV:
Have you previously filed a Title VI complaint with this agency? [  ]  Yes     [  ]  No
Section V: 
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court? [  ]  Yes     [  ]  No
If yes, check all that apply: 
[  ]  Federal Agency  _______________  [  ]  Federal Court  _______________ 
[  ]  State Agency  _______________  [  ]  State Court ________________ 
[  ]  Local Agency  _______________ 
Please provide information about a contact person at the agency/court where the complaint was filed. 
Name: Title:
Agency: Telephone:
Address: 
 
 

You may attach any written materials or other information that you think is relevant to your complaint.
 
Signature and date required below 
 
 
 
Signature Date
 
 
 
 
Please submit this form by one of the following methods:
In person or by US Post Office                                                            Email:  mail@prebleseniorcenter.org

Preble County Council on Aging, Inc.                                                
Executive Director, Customer Complaint Representative             Fax:  937-456-6565 
800 East St. Clair Street 
Eaton, Ohio 45320