Title VI Complaint Form

Please note: Partially completed information cannot be saved, be sure to have all details with you before beginning the form. For the best form completion experience, use the Google Chrome browser. Upon submission, you will receive an email confirming receipt of your complaint.

For more details, visit https://nyserda.ny.gov/About/Doing-Business-with-NYSERDA. If you have any questions, contact TitleVI@nyserda.ny.gov.

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Contact Information

Phone Number

Phone Extension

Preferred method of contact

Phone

U.S. Mail

Date of alleged discriminatory conduct

Provide information regarding the NYSERDA Program or action with which you are concerned

Name and contact information of any possible witnesses

Do you require any specific accommodation for future communication (Braille, language interpretation, etc.)?

Authorized Signature

First Name

Last Name

Choose how to sign

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.