Title VI Compliant Forms

Job Title: Title VI Compliant Forms

Job Description:

The City of Benton policy ensures nondiscrimination compliance, on the grounds of race, color, national origin, age, sex, religion (not applicable as a protected group under the FMCSA Title VI Program), disability, limited English proficiency (LEP), or low-income status as provided by Title VI of the Civil Rights act of 1964 and related Nondiscrimination authorities.

Title 42 U.S.C. Sections 2000d

Executive Order 13166 ensures individuals whose first language is not English and has a limited capacity to read, write or understand English have meaningful access to programs, information and services by any entity receiving Federal funding. Please provide the following information necessary in order to process your complaint. A formal complaint must be filed within 180 days of the occurrence of the alleged discriminatory act. Assistance is available upon request. Please contact Jennifer Perry (501) 776-5900.      

Complete this form and return to:

The City of Benton

 Attn: Jennifer Perry, Human Resources Director (ADA/504/Title VI Coordinator)

114 South East Street, Benton, AR 72015 (501) 776-5900

Complainant's Name: ______________________________________________________________________________

Address: _______________________________    City: _____________________________

State: ______________________  Zip Code: _____________________________________

Telephone (Home): ___________________ Telephone (Work): __________________________

Person(s) discriminated against (if other than complainant)

Name: ______________________________________________________________________________

Address: _________________________    City: _____________________________

State: ________________________    Zip Code: _______________________________

Telephone (Home): ____________________Telephone (Work): __________________________

What is the discrimination based on?        Race     Color            National Origin

  Disability   Income   Limited English Proficiency (LEP)         Sex     Age       

Date of the alleged discrimination: ________________  Location: ___________________

Agency or person that was responsible for the alleged discrimination:

______________________________________________________________________________

______________________________________________________________________________

Have you filed this complaint with any other Federal, State, or local agency? If so, whom?

______________________________________________________________________________

______________________________________________________________________________

What remedy are you seeking? ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

List names and contact information of persons who may have knowledge of the alleged discrimination.

______________________________________________________________________________

______________________________________________________________________________

Describe the alleged discrimination. Explain what happened and whom you believe as responsible.

______________________________________________________________________________

______________________________________________________________________________

Complainant should sign and date. The complaint will not be accepted if it has not been signed. You may attach any written materials or other supporting information you think is relevant to your complaint.

_________________________________________                          ________________________

Signature                                                                                                                     Date