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2. This form is for individuals who wish to file a complaint because they did not receive appropriate language assistance to access public services from a City of Holland department, due to their level of proficiency in English language, as required by the Title VI of the Civil Rights Act of 1964.

4. First Name
5. Last Name
7. Today's Date
   Today's Date
8. Phone Number
9. Email Address
11. Address
13. City
14. State
15. Zip Code
17. Preferred Language(s)
19. What is your preferred method to contact you?

    1. Phone Call
    2. Email
    3. Mail
21. Is someone else helping you file this complaint? If Yes, please include their contact information.

    1. Yes
    2. No
23. Name
24. Email Address
26. Phone Number
28. What language(s) do you need services in?
30. What was the problem? Check all that apply.

    1. I was not offered an interpreter.
    2. I asked for an interpreter and was denied.
    3. The interpreter provided was not proficient in my preferred language.
    4. Documents or forms unavailable in my preferred language.
    5. I was charged for translation and/or interpretation services.
    6. Other
32. If you selected Other above, please explain:
34. When did this incident happen? If it happened more than once, indicate the date of the most recent incident.
    When did this incident happen? If it happened more than once, indicate the date of the most recent incident.

    When did this incident happen? If it happened more than once, indicate the date of the most recent incident.
36. Where did this incident happen?

    1. Over the phone
    2. In person
    3. Other
38. If you selected Other above, please explain:
40. Name of department with whom you interacted.
42. Did you complain to anyone from the department? If Yes, provide the following details.

    1. Yes
    2. No
44. First and Last name of person you contacted.
45. Date you made the complaint.
    Date you made the complaint.
47. Did you receive a response to your complaint?

    1. Yes
    2. No
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field