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Title VI Civil Rights Complaint Form

  1. City of Palmdale Circular Logo

  2. Title VI Civil Rights Complaint Form

    The following information is necessary to assist us in processing your complaint. If information is needed in another language, please contact (661) 267-5115.

    Complete and return this form to:
    City of Palmdale - City Clerk Department
    38300 Sierra Highway, Suite C
    Palmdale, CA 93550

  3. Person discriminated against (if someone other than the Complainant):

  4. Which of the following best describes the reason you believe the discrimination took place? Was it because of your:

  5. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?

  6. If yes, check each box that applies:

  7. Please provide information about a contact person at the agency/court where the complaint was filed:

  8. Please sign below. You may attach any written materials or other information that you think is relevant to your complaint.

  9. Leave This Blank: