Vinton, VA · Roanoke County
Title VI Discrimination Complaint Form
This optional form lets a person or authorized representative submit a discrimination complaint to the Town of Vinton and describe the incident and requested corrective action.
What this form is
The Town of Vinton provides this optional form for people who want to file a Title VI discrimination complaint. It asks for the complainant’s contact information, the reason for the complaint, incident details, a description of the complaint, and requested corrective action. If an authorized representative files for someone else, the form requests the representative’s information and signatures and asks that affected complainants be identified by name.
Who needs it
A person wishing to submit a discrimination complaint, or an authorized representative filing on another person’s behalf, may use this optional form.
How to submit it
Complete the form in blue or black ink or type, sign it, and submit it to the ADA & Title VI Coordinator at 311 S. Pollard Street, Vinton, VA 24179.
About notarization
This form is signed without a notary; the complainant or authorized representative signs and dates it, and the document lists no notarized or sworn attachment.
How to submit this form
- 1
Download The Form
Download the Town of Vinton Title VI Discrimination Complaint Form.
- 2
Complete The Form
Fill it out completely in blue or black ink or type, including the incident details and requested corrective action.
- 3
Sign And Date
The complainant and, if applicable, authorized representative should sign and date the form.
- 4
Submit To The Coordinator
Submit the completed form to the ADA & Title VI Coordinator at 311 S. Pollard Street, Vinton, VA 24179.
Frequently asked questions
- Do I need a notary for the Title VI Discrimination Complaint Form?
- No. The form has signature and date lines for the complainant and authorized representative, but no notary block. It lists no notarized or sworn attachment.
- How do I submit the discrimination complaint form?
- Complete the form in blue or black ink or type, sign it, and submit it to the ADA & Title VI Coordinator at 311 S. Pollard Street, Vinton, VA 24179.
- What information does the form ask for?
- It asks for contact details, the reason and details of the incident, a description of the complaint, requested corrective action, and information about witnesses.
- Can someone file this form for another person?
- Yes. The form says an authorized representative may file for another person and must include their own personal information. It also asks that all complainants be identified by name.