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The form collects complainant identity and contact information, the basis of the complaint (e.g., race, color, national origin), dates and locations of alleged discriminatory actions, and a detailed description of how discrimination occurred and how others were treated differently. It also requests retaliation information, responsible individuals and witnesses, related prior filings, discussion with representatives, the remedy sought, and additional supporting materials; it requires a signed and dated submission.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/title-vi-complaint-form-rev-0420-city-of-leander/306961/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/title-vi-complaint-form-rev-0420-city-of-leander/306961.png","ImageObject",442,249,{"name":88,"@type":89},"\tJames","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Where should the completed Title VI Complaint Form be submitted?","Question",{"text":109,"@type":110},"Submit the completed form to the City of Leander, attn: Safety and Risk Manager, Human Resources Department, PO Box 319, Leander, TX 78646.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information is required about the alleged discriminatory action?",{"text":114,"@type":110},"Provide the earliest and most recent dates of discrimination and describe how you were discriminated against, including why you believe your protected status was a factor and how others were treated differently.",{"name":116,"@type":107,"acceptedAnswer":117},"Is an unsigned complaint accepted?",{"text":118,"@type":110},"No. The form states that the City cannot accept an unsigned complaint, and it must be signed and dated by the complainant.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306961,1790473247,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},2336474466412,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Title VI Complaint Form (Rev. 04/20) Page 1 of 2  \nPlease submit completed form to:  \nCity of Leander  \nattn: Safety and Risk Manager Human Resources Department PO Box 319  \nLeander, TX 78646  \n\n| Last Name:   Mailing Address:\u003Cbr>City:   Main Phone Number:  \u003Cbr>Email Address: | First Name:   |\n| --- | --- |\n|  | State:   Zip Code:  \u003Cbr>Alternative Phone Number:   |\n\nPlease indicate the basis of your complaint:  \n Race  \n Color  \nNational Origin    Other Class    \nDate and place of alleged discriminatory action(s) . Please include the earliest date of discrimination and the most recent date of discrimination.  \nHow were you discriminated against? Describe the nature of the action, decision, or conditions of the alleged discrimination. Explain as clearly as possible what happened and why you believe your protected status (basis) was a factor in the discrimination. Include how other persons were treated differently from you. (Attach additional pages, if necessary) .  \nThe law prohibits intimidation or retaliation against anyone because he/she has either taken action, or participated in action, to secure rights protected by these laws. If you feel that you have been retaliated against, separate from the discrimination alleged above, please explain the circumstances below. Explain what action you took which you believe was the cause for the alleged retaliation.  \nNames of individuals responsible for the discriminatory action(s):  \n(Rev. 04/20) Page 2 of 2  \nNames of persons (witnesses, fellow employees, supervisors, or others) whom we may contact for additional information to support or clarify your complaint (attach additional pages, if necessary) :  \nName Address Telephone  \n1.  \n2.  \n3.  \n4.  \nHave you filed, or intend to file, a complaint regarding the matter raised with any of the following? If yes, please provide the filing dates. Check all that apply.  \n U.S. Department of Transportation Date Filed:    \n Federal Highway Administration Date Filed:    \n Federal Transit Administration Date Filed:    \n Office of Federal Contract Compliance Programs Date Filed:    \n Texas Department of Transportation Date Filed:    \n U.S. Equal Employment Opportunity Commission Date Filed:    \n U.S. Department of Justice Date Filed:    \n Other:   Date Filed:    \nHave you discussed the complaint with any  ( Name of Recipient)  representative? If yes, provide the name, position, and date of discussion.  \nBriefly explain what remedy, or action, you are seeking for the alleged discrimination.  \nPlease provide any additional information and/or photographs, if applicable, that you believe will assist with an investigation.  \nWe cannot accept an unsigned complaint. Please sign and date the complaint form below.  \nComplainant's Signature Date","cbCaicXy3LcUS53S","https://ap.wps.com/l/cbCaicXy3LcUS53S","pdf",111418,"English","# Complainant Information\n## Complaint Basis and Allegations\n## Retaliation (If Applicable)\n# Responsible Individuals and Witnesses\n## Prior Complaints and Discussions\n# Remedy Sought and Supporting Materials\n## Signature and Date","[{\"question\":\"Where should the completed Title VI Complaint Form be submitted?\",\"answer\":\"Submit the completed form to the City of Leander, attn: Safety and Risk Manager, Human Resources Department, PO Box 319, Leander, TX 78646.\"},{\"question\":\"What information is required about the alleged discriminatory action?\",\"answer\":\"Provide the earliest and most recent dates of discrimination and describe how you were discriminated against, including why you believe your protected status was a factor and how others were treated differently.\"},{\"question\":\"Is an unsigned complaint accepted?\",\"answer\":\"No. The form states that the City cannot accept an unsigned complaint, and it must be signed and dated by the complainant.\"}]","Title VI Complaint Form - Rev. 04/20 - City of Leander | PDF",1789842699]