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Title VI Complaint Form

  1. 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.

  2. (MM/DD/YYYY)

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

  4. (MM/DD/YYYY)

  5. Name of agency and department that allegedly discriminated:

  6. (MM/DD/YYYY)

  7. (MM/DD/YYYY)

  8. 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.

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  10. This field is not part of the form submission.