Non-Discrimination Complaint Form

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Non-Discrimination Complaint Form

The City of Seaford is committed to ensuring that no person is excluded from participation in, denied the benefits of, or subjected to discrimination in any program, service, or activity receiving financial assistance from the U.S. Environmental Protection Agency (U.S. EPA) on the basis of race, color, national origin, sex, disability, age, or other protected status as provided by applicable law.

If you believe you have been subjected to discrimination, please complete this form.

Non-Discrimination Complaint Form

1. COMPLAINTANT

NAME:

ADDRESS LINE 1:

ADDRESS LINE 2:

CITY: STATE: ZIP CODE:

PHONE: E-MAIL:

2. PERSON DISCRIMINATED AGAINST (IF DIFFERENT FROM COMPLAINTANT)

NAME:

ADDRESS:

CITY: STATE: ZIP CODE:

3. INCIDENT INFORMATION

DATE OF INCIDENT:

TIME OF INCIDENT:

LOCATION OF INCIDENT:

DEPARTMENT / PROGRAM / ACTIVITY INVOLVED (IF KNOWN):

Security Measure