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2. Filing a complaint with Grand County is voluntary. However, without the information requested in this form, we may be unable to proceed with your complaint. We collect this information under authority of Section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, Title II of the Americans with Disabilities Act and their implementing regulations. It is illegal for a recipient of Federal financial assistance to intimidate, threaten, coerce, discriminate or retaliate against you for filing a complaint or for taking any other action to enforce your rights under these Federal civil rights laws. Grand County also collects information under authority of Section 1553 of the Affordable Care Act, the Church Amendments, the Coats-Snowe Amendment, the Weldon Amendment, the Religious Freedom Restoration Act, as well as other Federal civil rights, conscience protections and religious liberty statutes. It may also be illegal for a recipient of Federal financial assistance to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under these Federal laws. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible discrimination, for internal systems operations, or for routine uses, which include disclosure of information outside Grand County Government for purposes associated with civil rights compliance and as permitted by law. You are not required to use this form. You also may write a letter or submit a complaint electronically with the same information. 

4. First Name*
5. Last Name*
7. Home Phone*
8. Mobile Phone
10. Address1
12. Address2
14. City
15. State
16. Zip
18. Email Address
20. Are you filing this complaint for someone else?
    -- Select One --YesNo
21. If yes, whose civil or conscience and religious rights do you believe were violated?
23. I believe that I have been (or the individual named above has been) discriminated against by Grand County Government on the basis of:*

    1. Race / Color / National Origin
    2. Age
    3. Disability
    4. Religion / Conscience
    5. Sex
    6. Other
24. When do you believe the civil rights or conscience and religious freedom discrimination occurred? *

    List date(s)

26. Briefly describe what happened: How and why do you believe that you have been (or someone else has been) discriminated against? Please be as specific as possible.*
28. Do you need special accommodations for Grand County Government to communicate with you about this complaint? (Check all that apply.)

    1. Braille
    2. Large Print
    3. Computer
    4. Electronic Mail
    5. TDD
    6. Sign language interpreter
    7. Foreign language interpreter
    8. Other
29. If you need a sign language or foreign language interpreter, please specific language:
31. Consent*
    -- Select One --I agree and give consent.I do not agree, and do not give consent.

    I have read, understand and agree to the above and give permission to Grand County to reveal my identity or identifying information about me in my case file to the persons at the entity or agency under investigation or to other relevant persons, agencies, or entities during any part of Grand County's investigation, conciliation, or enforcement process.  I understand that if I do not give permission to Grand County to reveal my identity or identifying information about me, this denial of consent is likely to impede the investigation of my complaint, and may result in closure of the investigation.

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field