Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.


  1. City of Battle Creek
    Title VI Complaint Form
  2. Title VI of the Civil Rights Act of 1964 states that "No person in the United States shall on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefit of, or otherwise be subjected to discrimination in any program, service, or activity receiving federal assistance."
    This form may be used to file a complaint with the City of Battle Creek based on violations of Title VI of the Civil Rights Act of 1964. You are not required to use this form; a letter that provides the same information may be submitted to file your complaint. Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to know the act was discriminatory within 180 day period, you have 60 days after you became aware to file your complaint.
  3. If you need assistance completing this form, please contact Ted Dearing by phone at (269)966-3378 or via e-mail at
  4. Individual(s) discriminated against, if different than above.
  5. Date(s) of alleged discrimination:
  6. Alleged Discrimination
  7. If your complaint is in regard to discrimination in the delivery of services or discrimination that involved the treatment of you by others by the agency or department indicated above, please indicate below the basis on which you believe these discriminatory actions were taken.
  8. NOTE
    The City of Battle Creek prohibits retaliation or intimidation against anyone because that individual has either taken action or participated in action to secure rights protected by policies of the City. Please inform Ted Dearing listed above if you feel you were intimidated or experience perceived retaliation to filing this complaint.
  9. Leave This Blank:

  10. This field is not part of the form submission.