Suffolk County, NY · Suffolk County
Service Discrimination Complaint Form
Suffolk County residents who believe they experienced discrimination in a county program or activity use this form to submit a complaint to Social Services.
At a glance
- Issued by
- City of Suffolk County · Suffolk County, Suffolk County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- suffolkcountyny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this form to report alleged discrimination in a Suffolk County program or activity based on race, color, national origin, disability, gender, age, income status, or limited English proficiency. It asks for contact details, information about the affected person, the date and circumstances of the incident, and details about related complaints filed elsewhere. The complainant signs and dates the form.
Who needs it
A person alleging discrimination in a Suffolk County program or activity, or someone authorized to file on that person's behalf, can submit this complaint.
How to submit it
Submit the completed form to the Title VI Designee, Commissioner’s Office, 3085 Veterans Memorial Highway, Ronkonkoma, NY 11779. The form also lists [email protected] and fax 631-854-9996.
About notarization
This complaint form is signed and dated without a notary; the complainant or aggrieved party may sign, and no notarized attachment is identified.
How to submit this form
- 1
Download the Form
Download the Service Discrimination Complaint Form PDF.
- 2
Complete the Sections
Provide contact information and describe the alleged discrimination. Complete the representative section if filing for someone else.
- 3
Gather Supporting Materials
Attach any written materials or other information relevant to the complaint; use additional sheets if needed.
- 4
Sign and Submit
Sign and date the form, then send it to the Title VI Designee at the address, email, or fax listed on the form.
Frequently asked questions
- Do I need a notary for the Service Discrimination Complaint Form?
- No. Sign and date the complaint form; the complainant or aggrieved party may sign. The form does not identify a notarized attachment.
- How do I submit the Service Discrimination Complaint Form?
- Send it to the Title VI Designee, Commissioner’s Office, 3085 Veterans Memorial Highway, Ronkonkoma, NY 11779. The form also lists an email address and fax number.
- What information does the complaint form ask for?
- It asks for contact details, information about the person affected, the incident date and circumstances, the suspected reason for discrimination, and information about related complaints.
- Can someone file the complaint for another person?
- Yes. The form asks for the representative’s relationship and reason for filing, confirmation of permission, and the aggrieved party’s signature.