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City of Port Orchard Complaint FormCity Clerk's Office Obte 2le Prospect Street Port Orchard, 87 98366 -44070�����D citvclerk c�portorchardwa.gov I (360) 876-4407 www.portorchardwa.gov TITLE VI COMPLAINT FORM If you believe that you have been discriminated against because of your race, color, or national origin (including limited English proficiency), by agency programs or activities, you may file a formal complaint by completing this form and send by e-mail to cityclerk@portorchardwa.gov, or send by postal mail to Attn: City Clerk, 216 Prospect Street, Port Orchard, WA 98366 Your Name: Phone Number: Email: Best time of day to contact you about this complaint: ❑ 8am-10m ❑ 10am-1pm ❑ 1pm-4:30pm Your mailing address (Street/PO Box, City State, Zip) What was the alleged discrimination based on? Select all applicable: ❑ Race ❑ Color ❑ National Origin (Including limited English proficiency) Date of alleged incident: Agency or person(s) responsible for the alleged discrimination: Name City State Zip Phone Number City Clerk's Office 216 Prospect Street Port Orchard, WA 98366 cityclerk&portorchardwa.gov 1 (360) 876-4407 www.portorchardwa.gov ORCHARD. Describe the alleged discrimination. Please explain what happened, why you believe it happened, and how you were discriminated against. Indicate who was involved. Be sure to include how you feel other persons were treated differently than you. Please attach any supporting documents to this form. City Clerk's Office T—iQ92le Prospect Street Port Orchard, 87 -4407 �����D citvclerk r�portorchardwa.gov 1 (360) 876-4407 www.portorchardwa.gov What remedy are you seeking for the alleged discrimination? Please note that this process will not result in the payment of punitive damages or financial compensation. List any other persons that we should contact for additional information in support of your complaint. Please include their phone numbers, addresses, email addresses, etc. Name City State Zip Email Phone Number List any other agencies with whom you have filed this same complaint: Signature (required): Date: City Clerk's Office 216 Prospect Street Port Orchard, 87 98366 -4407 wrtORCHARD citvclerkQportorchardwa.gov I (360) 876-4407 ww.poorchardwa.gov CITY OF PORT ORCHARD TITLE VI COMPLAINT PROCEDURES If you believe that you have been discriminated against because of your race, color, or national origin, then you have the right to file a formal complaint within 180 days of the alleged incident. HOW TO FILE A COMPLAINT 1.Complete the Title VI Complaint Form, answering every question. 2.Submit the signed complaint to: City of Port Orchard Attn: City Clerk 216 Prospect Street Port Orchard, WA 98366 or email cityclerk@portorchardwa.gov The complaint will then be forwarded to the federal funding agency through Washington State Department of Transportation -Office of Equal Opportunity. Complaints may also be filed directly with: Washington Sate Department of Transportation Office of Equity and Civil Right Att: Complaints P.O. Box 47314 Olympia, WA 98504-7314 or email: oecrcomplaints@wsdot.wa.90v The federal funding agency is responsible for all decisions regarding whether a complaint should be accepted and investigated, dismissed, or referred to another agency. When the federal funding agency decides whether to accept, dismiss, or transfer the complaint, it will notify the complainant and the other agencies (as appropriate) as to the status of the complaint. These procedures do not deny you the right to file a formal complaint directly with the federal funding agencies or seek private counsel for complaints alleging discrimination. Federal law prohibits intimidation or retaliation against you of any kind. These procedures cover all complaints filed under Title VI of the Civil Rights Act of 1964 as amended and the Civil Rights Restoration Act of 1987, relating to any program, service, or activity administered by WSDOT as well as its sub -recipients, consultants, and contractors.