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City of Sunny Isles Beach

18070 Collins Avenue

Sunny Isles Beach, FL 33160

305.792.1807

Title VI Complaint of Discrimination

Phone Number:

Email:

Please list the names, addresses and phone numbers of any witnesses:

Location of Incident:

Date of Incident:

Please explain how, why and where you believe you were discriminated against. Include as much background information as possible about the alleged acts of discrimination.

Complainant Signature:

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Today's Date:

Note: Alternate means of filing complaint, such as personal interviews or a tape recording of the complain, will be made available for persons with disabilities upon request.

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Title VI Complaint of Discrimination

Complainant Name:

Address:

Date of Incident:

Discrimination Because Of:

Complainant Signature:

Today's Date: