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Title VI Complaint Form

Title VI of the 1964 Civil Rights Act requires that ''No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." Note: Complaints must be filed within 180 days of the date of the alleged discrimination. The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please contact the Title VI Coordinator by email at: TitleVICoordinator@kirklandwa.gov or by phone at (425) 587-3875. Persons with hearing impairments may access the Washington State Telecommunications Relay Service at 711.
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Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?
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By submitting this form you attest the above statements made are true and factual to the best of your knowledge. This complaint will constitute a public record upon submittal to the City and may be subject to disclosure under the public records act (RCW 42.56) and in accordance with the City of Kirkland's website privacy policy