Orinda, CA · Contra Costa County
Title VI Complaint Form
The City of Orinda Title VI Complaint Form lets residents, contractors, consultants, and others report alleged discrimination to the city.
What this form is
Use this form to report alleged discrimination based on race, color, or national origin, or another specified basis. It asks for information about the complainant, incident, people involved, witnesses, supporting facts, and requested remedy, and asks whether prior complaints were filed. The form also requests supporting documents and a signature and date.
Who needs it
Anyone reporting an incident of alleged discrimination involving the City of Orinda can complete this form and provide supporting information.
How to submit it
Send the original to the City of Orinda Title VI Coordinator (HR Manager) in person at 22 Orinda Way, by email to [email protected], and by mail to the listed address.
About notarization
This complaint is signed and dated without a notary; attach any emails, photos, texts, or documents that support the complaint.
How to submit this form
- 1
Download The Form
Download the City of Orinda Title VI Complaint Form.
- 2
Complete The Complaint
Provide your contact details and information about the incident, witnesses, alleged discrimination, requested remedy, and any prior complaints.
- 3
Gather Supporting Documents
Attach any emails, photos, texts, or documents supporting your complaint. Add pages if needed for witness or incident details.
- 4
Sign And Submit
Sign and date the form, then send the original to the Title VI Coordinator in person, by email, and by mail as listed on the form.
Frequently asked questions
- Do I need a notary for the Title VI Complaint Form?
- No. The form asks you to sign and date the complaint, but it has no notary block. You may attach emails, photos, texts, or other supporting documents.
- How do I submit the Title VI Complaint Form?
- Send the original to the Title VI Coordinator (HR Manager) in person at 22 Orinda Way, by email to [email protected], and by mail to the address listed on the form.
- What information does the complaint form ask for?
- It asks for your contact information, incident dates and locations, people involved, witnesses, the basis of the complaint, supporting facts, requested remedy, and details of any prior complaints.
- Can I include supporting documents?
- Yes. The form asks you to attach supporting emails, photos, texts, or documents. It also allows additional pages for witness information and complaint details.
Need something notarized?
This Title VI Complaint Form doesn’t need a notary — but if you have another Orinda form that does, a commissioned online notary can help.