Title VI Complaint Form

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Please correct the field(s) marked in red below:

Thank you for filling out this complaint form. The City of Mesa is committed to ensuring that no person is excluded from participation, denied the benefits of, or subjected to discrimination by the City in relation to any program or activity administered by the City or its sub recipients, consultants, or contractors on the basis of race, color, or national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days from the date of the alleged discrimination.

The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact the Title VI Coordinator, Ruth Giese, by calling 480-644-5033 or sending an email request to diversity.info @mesaaz.gov.

If you wish to mail the completed form, please complete the fields of the form and then print the web page.  Mail pages to:

City of Mesa Title VI Coordinator, c/o Ruth Giese
PO Box 1466
Mesa, AZ 85211

SECTION I - Contact Information
SECTION I - Contact Information

Are you filing this complaint on your own behalf?

If Yes, please skip to Section III

If No, please provide the following Complainant Information for the person discriminated against


Are you filing this complaint on your own behalf? If Yes, please skip to Section III If No, please provide the following Complainant Information for the person discriminated against
SECTION II - Complainant Information
SECTION II - Complainant Information
SECTION III - Incident Description
SECTION III - Incident Description
 Which of the following best describes the reason you believe the discrimination occurred
Which of the following best describes the reason you believe the discrimination occurred
Explain as clearly as possible what happened and why you believe that you were discriminated
against. Describe all of the persons, program and/or services involved.
SECTION IV- Incident Information
Please list any and all witnesses’ names and phone numbers/contact information.
Have you discussed your complaint with anyone within the City of Mesa?
Have you discussed your complaint with anyone within the City of Mesa?
If yes, provide name(s) and position(s)
Have you filed your complaint with a federal, state, or local agency; or with a federal or state court?
Have you filed your complaint with a federal, state, or local agency; or with a federal or state court?
If yes, provide agency name and date filed
Section V- Accommodation
You may attach any written materials or other information you think is relevant to your complaint.

Signature and date are required

I affirm that the above is true to the best of my knowledge, information and belief.

 *
Signature and date are required I affirm that the above is true to the best of my knowledge, information and belief.
Filing this complaint with the City of Mesa Title VI Coordinator does not prevent you from filing a complaint with
the Federal Agency providing funding to the party against which a complaint is being lodged. For additional
information on location of state and federal offices contact the Title VI Coordinator at 480-644-5033
or send a request to the Diversity Office at diversity.info@mesaaz.gov.
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