Title VI Withdraw of Complaint Form

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Date*
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
I wish to withdraw my complaint*
- Yes
- No
Date complaint was filed*
MM slash DD slash YYYY
Person or agency complaint was filed against*
Address of person or agency complaint was filed against*
Street Address Address Line 2 City State ZIP Code
Reason for withdraw of complaint*