Title VI Grievance Form

If you feel you have been discriminated against, please complete the following webform in order to assist us in processing your complaint.

You may also complete the linked PDF form and mail or deliver it to:

Town of Cutler Bay
Attn: Alfredo Quintero, Jr., Title VI Coordinator
10720 Caribbean Boulevard, Suite 105
Cutler Bay, FL 33189

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Name: *

Address: *

City: *

State: *

Zip Code: *

Email:

Cell Phone Number: *

Home Phone Number:

Person discriminated against: *

Address of person discriminated against:

City:

State:

Zip Code:

Discrimination Reason: *

Please indicate why you believe the discrimination occurred (check all that apply).

Race

National Origin

Income

Other

If other, please provide details:

What was the date of the alleged discrimination *

Where did the alleged discrimination take place? *

Please describe the circumstances as you saw it: *

Please list any and all witnesses' names and phone numbers:

Please attach any documents which support the allegation:

Files must be less than 15 MB.
Allowed file types: gif jpg jpeg png txt pdf doc docx ppt pptx xls xlsx mov mp3 zip.

Additional documents:

Files must be less than 5 MB.
Allowed file types: gif jpg jpeg png txt pdf doc docx ppt pptx xls xlsx mov mp3 zip.

Confirming Complaint: *

By typing my full name below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.

Today's Date:

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Title VI Grievance Form

Contact Information