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2. Title VI Complaint Form

   Title VI of the Civil Rights Act of 1964 requires that “no person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” 

   If you feel you have been discriminated against on the basis of race, color or national origin through the City of Wray's provision of any program or activity (pursuant to Title VI of the Civil Rights Act of 1964), please complete this Title VI Complaint Form.    

   Please complete all questions to the best of your knowledge. If you need assistance in completing this form, including interpretation or translation assistance, please contact the City’s ADA Coordinator via email, at adacoordinator@cityofwray.org, or by calling 970.332.4431

4. PLEASE COMPLETE THE INFORMATION BELOW:

6. 1. Complainant
8. Complainant's Name
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
17. Email Address
19. 2. Person discriminated against (if someone other than Complainant)
21. Name
22. Address
24. City
25. State
26. Zip Code
28. Phone Number
30. Email Address
32. 3. Which of the following best describes the reason you believe the discrimination took place? (check all that apply)

    1. Race
    2. Color
    3. Natural Origin
    4. Limited English Proficiency
34. 4. City of Wray agency, department, or program complaint is about:
36. Name of Agency, Department, or Program
37. City Employee(s) Involved
39. 5. Date of incident (resulting in complaint)
    5. Date of incident (resulting in complaint)
41. 6. Location of incident (resulting in complaint)
43. 7. In your own words, describe the circumstances surrounding this complaint. Please provide as many details as possible, such as time of day, specific actions, events, interactions, names and job titles, who said what, who was present at the time, etc.
45. Circumstances leading to this complaint:
47. 8. Were there any witnesses to the incident?

    1. Yes
    2. No
49. 9. Have any efforts been made to file or resolve this complaint through the internal grievance procedures of any City of Wray's department

    1. Yes
    2. No
51. 10. Have you filed a complaint about this same incident with any other agency or court? If so, fill in the organization's name and contact person.
53. Federal Agency Name
54. Federal Agency Contact Person
56. Federal Court Name
57. Federal Court Contact Person
59. State Agency Name
60. State Agency Contact Person
62. State Court Name
63. State Court Contact Person
65. City/Local Agency Name
66. City/Local Agency Contact Person
68. City/Municipal Court Name
69. City/Municipal Court Contact Person
71. Other - Please provide the full contact information for the person with the "other" agency or court
73. Name
74. Affiliation
76. Address
78. City
79. State
80. Zip Code
82. Phone Number
83. Date
    Date
85. 11. Type your name in the space below to provide and electronic signature.
87. 12. Today's Date
    12. Today's Date
89. 13. In order to receive a copy of this complaint, please enter your email below.
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit

* indicates a required field