Exhibit B - Complaint Forms ADA/Title VI Discrimination Complaint Form "*" indicates required fields InstagramThis field is for validation purposes and should be left unchanged.Note: The following information is needed to assist in processing your complaint.Complainant's information:Name*Address Street Address City State / Province / Region ZIP / Postal Code Email* Home Phone Number*Alternate Phone Number*Person discriminated against (someone other than complainant)Name*Address Street Address City State / Province / Region ZIP / Postal Code Email* Home Phone Number*Alternate Phone Number*Which of the following best describes the reason you believe the discrimination took place? Please be specific. Race National Origin Color Disability On what date(s) did the alleged discrimination take place?Where did the alleged discrimination take place?What is the name and of the person(s) who you believe discriminated against you (if known)?Describe the alleged discrimination. Explain what happened and who you believe was responsible. If additional space is needed, add a sheet of paper.List contact information of persons who may have knowledge of the alleged discrimination.If you have filed this complaint with any other federal, state or local agency, or with any federal or state court, check all that apply.. Federal Agency Federal Court State Agency State Court Local Agency Name*Address Street Address City State / Province / Region ZIP / Postal Code Phone Number*Please sign below. You may attach any written materials or other information that you believe is relevant to your complaint.SignatureDate MM slash DD slash YYYY Submit any additional information to: Bullhead City MPO Attn: Steve D'Amico, Title VI Coordinator 2135 Highway 95, #145 Bullhead City, AZ 86442 Phone: (928) 201-8664 Email: sdamico@bullheadcityaz.gov
