INSTRUCTIONS:
The purpose of this form is to help any person interested in filing a discrimination complaint with the Town of Sellersburg. You are not required to use this form. You may write a letter with the same information, sign it, and return it to the address below. All bold items must be completed for your complaint to be investigated. Failure to provide complete information may impair the investigation of your complaint.
Title VI of the Civil Rights Act of 1964, as amended and its related statutes and regulations (Title VI) prohibit discrimination on the basis of race, color, national origin, sex, age, disability/handicap, or income status in connection with programs or activities receiving federal financial assistance for the United States Department of Transportation, Federal Highway Administration, and/or Federal Transit Administration. These prohibitions extend to the Town of Sellersburg as a sub-recipient of federal financial assistance.
Upon request, assistance will be provided if you are an individual with a disability or have limited English proficiency. Complaints may also be filed using alternative formats such as computer disk, audiotape, or Braille.
You also have the right to file a complaint with other state or federal agencies that provide federal financial assistance to the Town of Sellersburg. Additionally, you have the right to seek private counsel.
The Town of Sellersburgis prohibited from retaliating against any individual because he or she opposed an unlawful policy or practice, filed charges, testified, or participated in any complaint action under Title VI or other nondiscrimination authorities.
Please make a copy of your complaint form for your personal records. Do not send your original documents as they will not be returned. Mail the original complaint form along with any copies of documents or records relevant to your complaint to the address below.
Complaints of discrimination must be filed within 180 days of the date of the alleged discriminatory act. If the alleged act of discrimination occurred more than 180 days ago, please explain your delay in filing this complaint.
**Your complaint cannot be processed without your signature.
External Complaint Form