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City of San Leandro Title VI Compliant Form Page 1 <br />CITY OF SAN LEANDRO <br />Title VI of the Civil Rights Act of 1964 <br />Complaint Form <br /> <br />Complaints must be filed within 180 days of the alleged act of discrimination. <br /> <br />Section I <br /> <br />Name: ________________________________________________________________________ <br /> <br />Address: _______________________________________________________________________ <br /> <br />Telephone No. (Home): __________________________________________________________ <br /> <br />Telephone No. (Work): __________________________________________________________ <br /> <br />Electronic Mail Address: ___________________________________________________________ <br /> <br />Accessible Format Requirements? Check all that apply. <br /> Large print <br /> Audio Tape <br /> TDD <br /> Other _________________________________________ <br /> <br />Section II <br /> <br />Are you filing this complaint on your own behalf? ____ Yes* ____ No <br /> <br />* If you answered “Yes” to this question go to Section III. <br /> <br />If not, please provide the name and relationship of the person for whom you are filing this <br />complaint: _______________________________________________________________________ <br /> <br />Please explain why you are filing for this person: <br />_________________________________________________________________________________ <br />_________________________________________________________________________________ <br />________________________________________________________________________________. <br /> <br />Please confirm that you have obtained the permission of the complaining person if you are filing on <br />their behalf. ____ Yes ____ No <br /> <br />Section III <br /> <br />I believe the discrimination I experienced was based on (check all that apply): <br /> Race <br /> Color <br /> National Origin <br /> <br />Date of the alleged discrimination (Month, Day, Year): __________________________ <br />