OCR Scan (approximately)

This OCR scan may contain automatically generated text as generated using Apache Tika and Tesseract. It may not be correct. No effort has been made to correct any of these scans (so far). These OCR scans are also used in the site's Search feature. Please review the Search Policy for details about the site features. The OCR scan is provided here for reference purposes. It provides searchable text when the underlying document might not. But the scan process may not always work perfectly.

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
[email protected].
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