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Title VI Complaint Form

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Title VI Complaint FormHCS2022-12-14T10:43:43-05:00

Title VI Complaint Form

Title VI of the Civil Rights Act of 1964 states "No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." Please provide the following information necessary in order to process your complaint. Should you require any assistance in completing this form, please let us know. You may also print and mail this form to us at: Corporate Compliance Officer VNA at HCS P.O. Box 564 Keene, NH 03431

Name
Address
Are you filling this complaint on your own behalf?

If NO:

Please supply the name of the person for whom you are complaining and your relationship to them:
Name
Have you obtained permission to file on behalf of the complainant?

What was the alleged discrimination based on? (Check all that apply)
MM slash DD slash YYYY
Have you previously filed a Title VI complaint with this agency?
Have you previously filed this complaint with any other federal, state, or local agency, or with a federal or state court?
If YES, please check each agency the complaint was filed with:

Please provide the name of a contact person at the agency/court where the complaint was also filed:
Agency/Court Contact Name
Agency/Court Contact Address

Max. file size: 50 MB.
MM slash DD slash YYYY

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From locations in Keene, Charlestown, & Peterborough, HCS brings health, independence, and care to our friends and neighbors throughout southwestern New Hampshire.

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800-541-4145

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