COMPLAINANT INFORMATION

Name (first, middle and last):*

Address:*

Address Line 2:

City:*

State:*

Zip Code:*

Phone Number:*

PERSON/DEPARTMENT YOU BELIEVE DISCRIMINATED AGAINST YOU

Name:*

Title:

Name of Department:

Address:*

City:*

State:*

Zip Code:

Date of alleged discriminatory act? (month, day year):*

The alleged discrimination was based on:

Race Color Age Gender

National Origin Disability Ancestry Retaliation

Describe the alleged act(s) of discrimination:*

How would you like your complaint to be resolved?

Complaints of Discrimination must be filed within 180 days of the date of the alleged discriminatory act.

By clicking submit, you understand that you are submitting a preliminary complaint. While a Complainant may preliminarily submit his or her complaint by online form submission, mail, facsimile, or email to the Title VI Coordinator, a signed, original copy of the complaint must be mailed to the Title VI Coordinator to officially begin the complaint process. Any person with a disability may request to file his or her complaint using an alternative format.
Direct all complaints of discrimination pursuant to Title VI to:
Toni Biancardi, Title VI Coordinator
1240 N. Boo Road, Burns Harbor, IN 46304
Email: tbiancardi@burnsharbor-in.gov
Phone: (219) 771-3910
Facsimile: (219) 787-1353