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2. Section 1
4. Name*
5. Address*
7. Telephone (Mobile/Home)*
8. Telephone (Work)
10. Accessible Format Requirements?

    1. Large Print
    2. TDD
    3. Audio Tape
    4. Other
11. If other, please fill in below
15. Section 2
17. Are you filing this complaint on your own?
    -- Select One --YesNo
18. If you answered "Yes" to this question, go to Section 3.
20. If not, please supply the name and relationship of the person for whom you are complaining:
21. Please explain why you have filed for a third party:
22. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
    -- Select One --YesNo
26. Section 3
28. I believe the discrimination I experienced was based on (check all that apply):

    1. Race
    2. Color
    3. National Origin
    4. Age
    5. Disability
    6. Family or Religious Status
    7. Other
29. Other (Specify here):
31. Date of alleged discrimination (Month, Day, Year)*
32. Location*
34. Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.*
38. Section 4
40. Have you previously filed a Title VI complaint with this agency?
    -- Select One --YesNo
41. Please provide a date and case number if applicable
45. Section 5
47. Have you filed this complaint with any other Federal, State or local agency, or with any Federal or State Court?
    -- Select One --YesNo
48. If yes, check all that apply:

    1. Federal Agency
    2. Federal Court
    3. State Agency
    4. State Court
    5. Local Agency
49. If yes, please provide a case/reference number:
51. Please provide information about a contact person at the agency/court where the complaint was filed (Include name, title, agency, and address).
55. Section 6
57. Name of agency complaint is against:*
58. Contact person:
59. Title:
60. Telephone number:
62. You may attach any written materials or other information that you think is relevant to your complaint.
64. By checking the box below and submitting this form, I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.*

    1. I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.
66. If information is needed in another language, please contact (352) 689‐4400.
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68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

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