HomeMy Public PortalAboutTitle VI Complainant Release Form CITY OF RICHMOND
OFFICE OF HUMAN RESOURCES AND COMPLIANCE
50 NORTH FIFTH STREET, RICHMOND, INDIANA 47374
PHONE (765) 983-7200
COMPLAINANT CONSENT/RELEASE FORM
Name (first, middle, and last):
Address (number and street, city state and zip code):
Home telephone:
Work Telephone: Cellular telephone:
Case number(s) (if known)
I have read the Title VI Notice of Complainant and Interviewee Rights provided by the City of Richmond. As a complainant, I
understand that during an investigation it may become necessary for INDOT to reveal my identity to individuals outside of the City in
the course of verifying information or gathering facts and evidence to develop a basis for making a civil rights compliance
determination. I understand that it may be necessary for the City to share information, including personal details collected as part of
its complaint investigation. In addition, I understand that as a complainant I am protected by Title VI of the Civil Rights Act of 1964, as
amended, and its related statutes and regulations prohibiting intimidation or retaliation for taking action or participating in an action to
secure rights protected by the non-discrimination statues enforced by the City of Richmond.
Please read both paragraphs below, check your choice of CONSENT or CONSENT DENIED and sign below. (Please mark one.)
Consent
I have read and understand the above information and authorize the City of Richmond to disclose my identity to individuals as
needed during the course of the investigation for the purpose of verifying information or gathering facts and evidence relevant to the
investigation of my complaint. I authorize the City of Richmond to receive, review and discuss material and information about me
relevant to the investigation of my complaint. I understand that the material and information will be used for authorized civil rights
compliance and enforcement activities. I further understand that I am not required to authorize this release and volunteer to do so.
Consent Denied
I have read and understand the above information and do not want the City of Richmond to disclose my identity to any individual
during the course of the investigation. I understand this choice could delay the investigation of my complaint and may, in some
circumstances, result in an administrative closure of the investigation of my complaint without the City of Richmond making a
determination in my case.
Signature: Date signed (month, day, year):