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City of San Leandro Title VI Compliant Form Page 2 <br /> <br /> <br />Explain as clearly as possible what happened and why you believe you were discriminated against. <br />Describe all persons who were involved. Include the name and contact information of the person(s) <br />who discriminated against you (if known) as well as the names and contact informat ion of any <br />witnesses. <br />_________________________________________________________________________________ <br />_________________________________________________________________________________ <br />_________________________________________________________________________________ <br />_________________________________________________________________________________ <br />_________________________________________________________________________________ <br />________________________________________________________________________________. <br /> <br />Section IV <br /> <br />Have you previously filed a Title VI complaint with this agency? ____ Yes ____ No <br /> <br />Section V <br /> <br />Have you filled a complaint with any other Federal, State or local agency, or with any Federal or <br />State Court? ____ Yes* ____ No <br /> <br />* If “Yes”, check all that apply. <br /> Federal agency <br /> State Agency <br /> Federal Court <br /> State Court <br /> Local Agency <br /> <br />You may attach any written material or other information that you think is relevant to your <br />complaint. <br /> <br />Please sign here: _________________________________________________________ <br /> <br />Date: ____________________________________________________________ <br /> <br />Note: City cannot accept your complaint without a signature <br /> <br /> <br />Please mail your completed form to: <br /> <br />Language Assist Coordinator <br />City Manager’s Office <br />835 East 14th Street, Room 211 (second floor of City Hall) <br />San Leandro, California 94577 <br />Facsimile: (510) 577-3340 <br />E-mail: LanguageAssist@sanleandro.org <br />