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TITLE VI COMPLAINT FORM

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The Sacramento Metropolitan Air Quality Management District (the District) is committed to ensuring that no person is excluded from participation in, denied the benefits of, or subjected to discrimination under any program or activity receiving federal financial assistance, per Title VI of the Civil Rights Act of 1964 and related statutes.

If you believe you have been discriminated against based on race, color, national origin, sex, age, or disability, please complete this form and submit it. Once you sbmit it it will automatically be sent to the Title VI Coordinator named below. Please provide the following information in order to assist us in processing your complaint:

Phone Number of Submitter

Email of Submitter

As the submitter, are you also the person discriminated against?

Yes

Please indicate why you believe the discrimination occurred

Race

Color

National Origin

Gender

Age

Disability

Other

If "Other", please explain

What was the date of the alleged discrimination?

Where did the alleged discrimination take place?

Please describe the discrimination as you saw it:

Please list any witnesses' names and phone numbers

Have you previously filed a Title VI complaint with the Sac Metro Air District

Yes

Have you filed this complaint with any other Federal, State, or local agency?

Yes

If yes to the previous question, please list the agency or agencies, including contact information, where the complaint was filed:

Please attach any documents you have which support the allegation.

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Upon submittal, the District's Title VI Coordinator will receive your complaint via email. You will have an opportunity to save or print a copy for your records.

The District's Title VI Coordinator is:

Patrick Smith
email: psmith@airquality.org
telephone: 279-207-1123
address: 777 12th Street, Fl. 3, Sacramento, CA 95814

TITLE VI COMPLAINT FORM

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Full Name of Submitter

Full Address of Submitter

As the submitter, are you also the person discriminated against?

Full Name of Person Discriminated Against (if different than submitter)

Full Address of Person Discriminated Against (if different than submitter)

Please indicate why you believe the discrimination occurred

What was the date of the alleged discrimination?

Have you previously filed a Title VI complaint with the Sac Metro Air District

Have you filed this complaint with any other Federal, State, or local agency?

Please attach any documents you have which support the allegation.