CIVIL RIGHTS ACT COMPLAINT FORM
Los Angeles County Public Works (Public Works) is committed to ensuring compliance with
Title VI of the Civil Rights Act of 1964 and other nondiscrimination authorities, that no person shall be
excluded from participation in or be denied the benefits of, or be subjected to discrimination under any
program or activity sponsored or implemented by Public Works on the grounds of race, color, national
origin, sex, age, disability, religion, sexual orientation, gender identity, or any other category
protected by State or Federal law. If you believe you have been discriminated against, please complete this
form.
Person Completing Form
(select one):
* An authorized representative is a person with authority to act in the best interest of the
participant.