Title VI Discrimination Complaint Form
Form
August 02, 2026
Title VI Discrimination Complaint Form
St. Louis County Title VI Discrimination Complaint Form
Complainant Information
First Name
Last Name
Address
City
State
Zip
Phone
Email
Is the Complainant represented by an attorney?
Yes
No
Attorney's Name
Attorney Phone
Attorney's Email
Basis of alleged discrimination. (Check all that apply.)
Race
Color
National Origin
Organization Information
Agency, business, or contractor that allegedly discriminated
Name of Person(s)/ Title
Address
City
State
Zip
Phone
Please explain in detail what happened, when, where, who was involved, and how discrimination occurred. If necessary, provide a copy of written materials pertaining to this complaint:
Other persons who have knowledge of the alleged discrimination
Person 1 Name
Person 1 Organization/Title
Person 1 Phone
What is the proposed remedy to this complaint?
Has a complaint, grievance, or lawsuit been filed with any other agency or court?
Yes
No
With whom?
When?
Status (pending, resolved, etc.)
Complaint or case number? (If known)
Submission
Enter email address to receive confirmation email
Submit
