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Appendix B <br /> <br />Title VI Complaint Form <br /> <br />Please complete this form to the best of your ability. If you need translation or other assistance, <br />contact Laura Linehan, Assistant City Administrator, at 651-766-4029. <br /> <br />Name_________________________________________________________________ <br />Address_______________________________City________________Zip___________ <br />Phone: Home_________________ Work_____________ Mobile___________________ <br />Email: _______________________________________________________________ <br /> <br />Basis of Complaint (circle all that apply): <br /> <br />☐ Race ☐ Color ☐ Creed ☐ Gender Identity <br />☐ National Origin ☐ Sex ☐ Religion ☐ Public Assistance Status <br />☐ Age ☐ Disability ☐ Marital Status ☐ Other <br />☐ Retaliation ☐ Low-Income ☐ Sexual Orientation <br /> <br />Who discriminated against you? <br /> <br />Name_________________________________________________________________ <br />Name of Organization____________________________________________________ <br />Address________________________________ City________________ Zip________ <br />Telephone_____________________________ <br /> <br />How were you discriminated against? (Attach additional pages if more space is needed) <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />_____________________________________________________________________ <br />_____________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________ <br />______________________________________________________________________