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Title VI Complaint Form

75 East 6th Street, Hialeah, FL 33010
Phone 305.888.9744 | TTY 305.887.2525
Office Hours: Monday - Friday | 8:30 am - 5:30 pm

Section 8 Department
Phone 305.887.9844 | Fax 305.882.5812

Fields marked with * must be filled out or form will not submit.

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Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Zip Code","name":"Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Telephone (Home)","name":"Telephone-Home","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Telephone (Work)","name":"Telephone-Work","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"email","className":"col-md-6"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"email-confirmed","className":"col-md-6"},{"type":"checkbox-group","required":true,"label":"Accessible Format Requirements?","inline":true,"name":"Accessible-Format-Requirements","other":true,"className":"d-block","values":[{"label":"Large Print","value":"large-print"},{"label":"Audio Tape","value":"audio-tape"},{"label":"TDD","value":"tdd"},{"label":"N/A","value":"n-a"}]},{"type":"header","subtype":"h4","label":"Section II","className":"d-block"},{"type":"radio-group","required":true,"label":"Are you filing this complaint on your own behalf?","inline":true,"name":"Are-you-filing-this-complaint-on-your-own-behalf","className":"d-block","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"paragraph","subtype":"p","label":"If you answered \"Yes\" to the question above, go to Section III.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","required":true,"label":"If you answered \"No,\" please supply the name and relationship of the person for whom you are complaining:","name":"If-you-answered-No-please-supply-the-name-and-relationship-of-the-person-for-whom-you-are-complaining","className":"d-block","subtype":"text"},{"type":"textarea","label":"Please explain why you have filed for a third party:","name":"Please-explain-why-you-have-filed-for-a-third-party","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. ","inline":true,"name":"Please-confirm-that-you-have-obtained-the-permission-of-the-aggrieved-party-if-you-are-filing-on-behalf-of-a-third-party-","className":"d-block","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"header","subtype":"h4","label":"Section III","className":"d-block"},{"type":"checkbox-group","required":true,"label":"I believe the discrimination I experienced was based on: (Check all that apply)","name":"I-believe-the-discrimination-I-experienced-was-based-on-Check-all-that-apply","other":true,"className":"d-block","values":[{"label":"Race","value":"race"},{"label":"Color","value":"color"},{"label":"National Origin","value":"national-origin"},{"label":"Age","value":"age"},{"label":"Disability","value":"disability"},{"label":"Family or Religious Status","value":"family-or-religious-status"}]},{"type":"date","required":true,"label":"Date of Alleged Discrimination:","name":"Date-of-Alleged-Discrimination","className":"d-block"},{"type":"textarea","required":true,"label":"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 the names and contact information of any witnesses.","name":"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-persons-who-discriminated-against-you-if-known-as-well-as-the-names-and-contact-information-of-any-witnesses","subtype":"textarea","rows":8,"className":"d-block"},{"type":"header","subtype":"h4","label":"Section IV","className":"d-block"},{"type":"radio-group","required":true,"label":"Have you previously filed a Title VI complaint with this agency?","inline":true,"name":"Have-you-previously-filed-a-Title-VI-complaint-with-this-agency","className":"d-block","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"header","subtype":"h4","label":"Section V","className":"d-block"},{"type":"radio-group","required":true,"label":"Have you filed this complaint with any other Federal, State, or local agency or with any Federal or State court?","inline":true,"name":"Have-you-filed-this-complaint-with-any-other-Federal-State-or-local-agency-or-with-any-Federal-or-State-court","className":"d-block","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"checkbox-group","required":true,"label":"If yes, check all that apply:","name":"If-yes-check-all-that-apply","className":"d-block","values":[{"label":"Federal Agency","value":"Federal-Agency"},{"label":"State Agency","value":"state-agency"},{"label":"Federal Court","value":"Federal-court"},{"label":"State Court","value":"state-court"},{"label":"Local Agency","value":"local-agency"}]},{"type":"text","required":true,"label":"Provide the name of the entity or entities selected above:","name":"Provide-the-name-of-the-entity-or-entities-selected-above","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"Please provide information about a contact person at the agency/court where the complaint was filed.","className":"d-block"},{"type":"text","required":true,"label":"Name of Contact:","name":"Name-of-Contact","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Title of Contact:","name":"Title-of-Contact","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Agency:","name":"Agency","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Address of Agency:","name":"Address-of-Agency","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Contact/Agency Telephone:","name":"ContactAgency-Telephone","className":"col-lg-4","subtype":"text"},{"type":"header","subtype":"h4","label":"Section VI","className":"d-block"},{"type":"text","required":true,"label":"Name of Agency complaint is against:","name":"Name-of-Agency-complaint-is-against","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Contact Person:","name":"Contact-Person","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Title of Contact Person:","name":"Title-of-Contact-Person","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Telephone Number of Contact Person:","name":"Telephone-Number-of-Contact-Person","className":"col-md-6","subtype":"text"},{"type":"file","label":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".<div><br></div><div>You may attach any written materials or other information that you think is relevant to your complaint.</div>","name":"You-may-attach-any-written-materials-or-other-information-that-you-think-is-relevant-to-your-complaint","subtype":"file","multiple":true,"className":"d-block"},{"type":"text","required":true,"label":"Signature:","placeholder":"By typing your name, you are signing this form.","name":"Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature:","name":"Date-of-Signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"Please submit form online, in person at the address below or mail this form to:<div>Legal Department</div><div>75 East 6th Street</div><div>Hialeah, FL 33010</div>","className":"d-block"}]

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