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2. Dubuque County Title VI Complaint Form

   This form may be used to file a complaint with Dubuque County based on a violation of Title VI of the Civil Rights Act of 1964.  You are not required to use this form.  A letter providing the same information may be submitted to file your complaint.

4. Name
5. Date
   Date

   (MM/DD/YYYY)

7. Address
9. City
10. State
11. Zip Code
13. Cell Phone Number
14. Home Phone Number

16. Individual(s) allegedly discriminated against if different than above (use additional pages if needed):

18. Name
19. Date
    Date

    (MM/DD/YYYY)

21. City
22. State
23. Zip Code
25. Cell Phone Number
26. Home Phone Number
28. Please explain your relationship to the individual(s) indicated above:
30. Address
32. City
33. State
34. Zip Code

36. Name of agency and department that allegedly discriminated:

38. Agency/Department Name:
40. Name of individual (If known)
42. Address
44. City
45. State
46. Zip Code
48. Date discrimination began:
    Date discrimination began:

    (MM/DD/YYYY)

49. Most recent date of discrimination
    Most recent date of discrimination

    (MM/DD/YYYY)

51. Alleged Discrimination

    If your complaint is in regard to discrimination in the delivery of services or discrimination that involved the treatment of you by others by the agency or department named on the previous page, please indicate below the basis on which you believe these discriminatory actions were taken.

    1. Race/Color
    2. Religion

    1. National Origin
    2. Age

    1. Gender
    2. Disability
53. Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and others involved in the alleged discrimination.
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field