TITLE VI DISCRIMINATION COMPLAINT

Table of Contents

1. Complainant Information
2. Respondent Information
3. Basis of Complaint
4. Statement of Facts
5. Legal Basis
6. Relief Requested
7. Declaration
8. State-Specific Notes
9. Practitioner Checklist

ADMINISTRATIVE COMPLAINT UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964

Filed with: [FEDERAL AGENCY NAME — e.g., U.S. Department of Education Office for Civil Rights, U.S. Department of Health and Human Services, U.S. Department of Transportation]

Date of Filing: [__/__/____]

I. COMPLAINANT INFORMATION

Name: [COMPLAINANT FULL NAME]

Address: [________________________________]

City, State, ZIP: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

Preferred Contact Method: ☐ Mail ☐ Email ☐ Telephone

Complainant is filing:
☐ On their own behalf
☐ On behalf of another person: [NAME]
☐ On behalf of a class of persons

II. RESPONDENT INFORMATION

Name of Entity (Recipient of Federal Funds): [________________________________]

Type of Entity:
☐ State agency
☐ Local government agency
☐ School or school district
☐ Hospital or healthcare provider
☐ Transportation authority
☐ Other federally funded program: [DESCRIBE]

Address: [________________________________]

Federal Funding Source(s): [IDENTIFY FEDERAL AGENCY AND PROGRAM — e.g., U.S. Department of Education Title I funds]

Contact Person (if known): [NAME AND TITLE]

III. BASIS OF COMPLAINT

The Complainant alleges discrimination on the basis of:
☐ Race
☐ Color
☐ National origin

Date(s) of Discriminatory Act(s): [________________________________]

Is the discrimination ongoing? ☐ Yes ☐ No

IV. STATEMENT OF FACTS

Background

1. [DESCRIBE THE COMPLAINANT'S RELATIONSHIP TO THE FEDERALLY FUNDED PROGRAM — e.g., student, patient, program participant, service recipient]

2. The Respondent receives federal financial assistance from [FEDERAL AGENCY] through [PROGRAM NAME / GRANT NUMBER, if known].

Discriminatory Conduct

3. On or about [DATE], the following discriminatory act(s) occurred: [PROVIDE DETAILED CHRONOLOGICAL ACCOUNT]

4. [DESCRIBE THE SPECIFIC CONDUCT — denial of services, differential treatment, hostile environment, retaliation, language access barriers, etc.]

5. The discriminatory conduct affected Complainant in the following ways:
   ☐ Denial of services or benefits
   ☐ Inferior quality of services compared to similarly situated persons of different race/color/national origin
   ☐ Segregation or separate treatment
   ☐ Hostile environment
   ☐ Retaliation for prior complaint or advocacy
   ☐ Failure to provide language access services (Limited English Proficiency)
   ☐ Other: [DESCRIBE]

Comparator Evidence

6. Similarly situated individuals of [different race / color / national origin] were treated more favorably in the following manner: [DESCRIBE]

Prior Reporting

7. The Complainant reported the discrimination to the Respondent as follows:
   ☐ Oral complaint on [DATE] to [NAME/TITLE]
   ☐ Written complaint on [DATE] to [NAME/TITLE]
   ☐ Complaint not previously reported because: [EXPLAIN]

8. The Respondent's response, if any: [DESCRIBE]

V. LEGAL BASIS

Title VI — Intentional Discrimination

9. Respondent intentionally discriminated against Complainant on the basis of [race / color / national origin] in violation of 42 U.S.C. § 2000d.

Title VI Regulations — Disparate Impact

10. Alternatively or additionally, Respondent's facially neutral policies or practices have a disparate impact on persons of Complainant's [race / color / national origin] in violation of Title VI implementing regulations. See, e.g., 28 C.F.R. § 42.104(b)(2) (DOJ); 34 C.F.R. § 100.3(b)(2) (Education).

Retaliation

11. Respondent retaliated against Complainant for [opposing discriminatory practices / filing a prior complaint / participating in an investigation] in violation of 42 U.S.C. § 2000d-7 and implementing regulations.

VI. RELIEF REQUESTED

Complainant respectfully requests the following relief:

☐ Investigation of the discriminatory practices
☐ Determination that Respondent violated Title VI
☐ Order requiring Respondent to cease discriminatory practices
☐ Order requiring Respondent to adopt corrective policies
☐ Compensatory damages for injuries suffered
☐ Monitoring of Respondent's compliance
☐ Referral to the Department of Justice for enforcement action
☐ Initiation of fund termination proceedings if voluntary compliance is not achieved
☐ Other: [DESCRIBE]

DECLARATION

I declare under penalty of perjury that the information provided in this complaint is true and correct to the best of my knowledge.

Signature: _______________________________

Printed Name: [________________________________]

Date: [__/__/____]

STATE-SPECIFIC NOTES

California

• State Equivalent: Unruh Civil Rights Act (Cal. Civ. Code § 51); Cal. Government Code § 11135 (discrimination in state-funded programs)
• Agency: California Department of Fair Employment and Housing (DFEH)

Texas

• State Equivalent: Texas Commission on Human Rights Act (Tex. Lab. Code Ch. 21) — limited to employment; no direct state equivalent for federally funded program discrimination
• Agency: Texas Workforce Commission Civil Rights Division

Florida

• State Equivalent: Florida Civil Rights Act (Fla. Stat. Ch. 760) — primarily employment and housing
• Agency: Florida Commission on Human Relations

New York

• State Equivalent: N.Y. Executive Law § 296 (Human Rights Law) — broad anti-discrimination protections
• Agency: New York State Division of Human Rights

PRACTITIONER CHECKLIST

☐ Confirmed Respondent receives federal financial assistance
☐ Identified specific federal funding agency and program
☐ Filed within 180-day administrative deadline (or confirmed equitable tolling grounds)
☐ Documented discriminatory acts with dates and specifics
☐ Identified comparator evidence (similarly situated individuals treated differently)
☐ Preserved documentary evidence (correspondence, policies, records)
☐ Determined whether to file administratively, in court, or both
☐ Assessed whether claim is intentional discrimination or disparate impact
☐ If disparate impact only — filed administratively (no private right of action per Alexander v. Sandoval)
☐ Considered language access / LEP discrimination under Executive Order 13166
☐ Evaluated retaliation claims if applicable

SOURCES AND REFERENCES

• 42 U.S.C. § 2000d et seq. — Title VI of the Civil Rights Act of 1964
• Alexander v. Sandoval, 532 U.S. 275 (2001) — no private right of action for disparate impact
• Lau v. Nichols, 414 U.S. 563 (1974) — Title VI and language discrimination
• Executive Order 13166 — Improving Access to Services for Persons with Limited English Proficiency
• 34 C.F.R. Part 100 — Department of Education Title VI regulations
• 28 C.F.R. Part 42 — Department of Justice Title VI regulations