Title VI Complaint Form

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Mayor Kevin Hartke

A Message From:

Mayor Kevin Hartke

Welcome to Chandler, Arizona, the Community of Innovation. Come meet Mayor Kevin Hartke and the members of the City Council.

Mayor and Council

Any person who believes that he or she has been discriminated against by the City of Chandler or any of its service providers in a federally funded program and believes the discrimination was based upon race, color, national origin, age or disability may file a formal complaint with the Title VI Coordinator.

Please provide the following information to process your complaint. Alternative formats and languages are available upon request. You can reach the city’s Connection & Impact Officer Niki Tapia at 480-782-2214. For people who are deaf, deaf-blind, hard of hearing or having difficulty speaking, dial 7-1-1 to connect with Arizona Relay Service.

Section 1: Customer Information

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Preferred method of contact

Phone

Section 2: Incident Information

Date of Incident

Time of Incident

Incident Location

What was discrimination based on (Check all that apply)

Race

Color

National Origin

Age

Disability

Other…

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. If more space is needed, please use the back of this form. You may also attach any written materials or other information relevant to your complaint.

Have you previously filed a Title VI complaint with the City of Chandler?

Yes

Signature and date required below:

Signature

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Date

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