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2. Cowlitz County Complaint Form

   Please complete this form to the best of your ability. If you need translation or other assistance, contact the Title VI Specialist or email titlevi@cowlitzwa.gov.

4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Email Address:*
17. Phone Number:
19. Basis for Complaint
    -- Select One --RaceColorNational OriginLanguage Access
21. Describe the Incident:

    Using details such as time, locaton,  names or descriptions of individuals involved, please explain what happened:

23. Remedy:

    Please identify the remedy you seek for the alleged discrimination. Please note, this process will not result in the payment of punitive damages or financial compensation. 

25. Other:

    Are there any other thoughts or details you feel are germane to the occurrence to note:

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field