---
type: document
title: DISCRIMINATION-COMPLAINT-FORM
file: ../DISCRIMINATION-COMPLAINT-FORM.pdf
tags:
  - Cumberland_Plateau_Planning_District_Commission
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---

DISCRIMINATION COMPLAINT FORM 

Please provide the following information in order to process your complaint. Assistance is 

available upon request. Complete this form and mail or deliver to: 

Cumberland Plateau Planning District Commission, Title VI Coordinator, P.O. Box 548, 224 

Clydesway Road, Lebanon, VA 24266  

You can reach our office Monday-Friday from 8:00 am to 5:00 pm at (276) 889-1778, or you 

can email the Cumberland Plateau Planning District Commission Title VI Coordinator at 

judyharris@bvu.net. 

Complainant's Name: _____________________________________________________________  

Street Address: __________________________________________________________________  

City: ____________________________  State: _______________________ Zip Code: _________  

Telephone No. (Home): _________________________ Business: __________________________  

Email Address: ________________________________  

Person discriminated against (if other than complainant): 

Name: _________________________________________________________________________  

Street Address: 

City: ____________________________  State: _______________________ Zip Code: ________  

Telephone No.: __________________________  

The name and address of the agency, institution, or department you believe discriminated against 

you. 

Name: ________________________________________________________________________  

Street Address: 

City: ____________________________ State: _______________________ Zip Code: 

Date of incident resulting in discrimination: __________________  

Describe how you were discriminated against. What happened and who was responsible? If 

additional space is required, please either use the back of form or attach extra sheets to form. 

DISCRIMINATION COMPLAINT FORM

Please provide the following information in order to process your complaint. Assistance is
available upon request. Complete this form and mail or deliver to:

Cumberland Plateau Planning District Commission, Title VI Coordinator, P.O. Box 548, 224
Clydesway Road, Lebanon, VA 24266

You can reach our office Monday-Friday from 8:00 am to 5:00 pm at (276) 889-1778, or you
can email the Cumberland Plateau Planning District Commission Title VI Coordinator at

judyharris@bvu.

Complainant's Name:

Street Address:

City: State: Zip Code:

Telephone No. (Home): Business:

Email Address:
Person discriminated against (if other than complainant):

Name:

Street Address:

City: State: Zip Code:

Telephone No.:

The name and address of the agency, institution, or department you believe discriminated against

you.

Name:

Street Address:
City: State: Zip Code:

Date of incident resulting in discrimination:

Describe how you were discriminated against. What happened and who was responsible? If
additional space is required, please either use the back of form or attach extra sheets to form,




Does  this  complaint  involve  a  specific  individual(s)  associated  with  the  Cumberland Plateau 

Planning District Commission? If yes, please provide the name(s) of the individual(s), if known. 

Where did the incident take place? 

Are there any witnesses? If so, please provide their contact information: 
Name: 

Street Address: 

City: __________________________  State: _______________________ Zip Code: 

Telephone No.: ________________________  

Name: _____________________________________________________________  

Street Address: 

City: __________________________ State: ______________________ Zip Code: _________  

Telephone No.: ________________________  

Did you file this complaint with another federal, state or local agency; or with a federal or state court? 
o    YES o    NO 

If answer is Yes, check each agency complaint was filed with: 
o Federal Agency 
o State Court 
o Federal Court 
o Local Agency 
o State Agency 
o Other 

Please provide contact person information for the agency you also filed the complaint 
with: 
 
 
Name: ______________________________________________________________  

Street Address: 

City: State: Zip 

Code: 

Telephone No.: 

 

Sign the complaint in the space below. Attach any documents you believe support your complaint. 

 

 

_________________________    __________________________ 

Complainant's Signature     Signature Date 

Does this complaint involve a specific individual(s) associated with the Cumberland Plateau
Planning District Commission? If yes, please provide the name(s) of the individual(s), if known.
Where did the incident take place?

Are there any witnesses? If so, please provide their contact information:
Name:

Street Address:

City: State: Zip Code:

Telephone No.:

Name:

City: State: Zip Code:

Telephone No.

Did you file this complaint with another federal, state or local agency; or with a federal or state court?
0 YES o NO

If answer is Yes, check each agency complaint was filed with:
© Federal Agency
State Court
Federal Court
Local Agency
State Agency
0 Other
Please provide contact person information for the agency you also filed the complaint
with:

eoo°

Name:

Street Address:

City: State Zip
Code:

Telephone No.:

Sign the complaint in the space below. Attach any documents you believe support your complaint.

‘Complainant's Signature Signature Date