Complete this form to report a discrimination complaint. (Customers should complete the form whenever possible.To file a formal complaint, please submit a written or online Title VI Complaint Form. Indicate the type(s) of complaint being filed: Discrimination ☐. Please complete all fields. If you have been subjected to unlawful discrimination, harassment, or retaliation, please complete and submit a complaint form. A blank form you can use to write out your petition is attached. Also attached is a sample that may be used as a guide. The form cannot be completed online. Medi-Cal beneficiaries may file for a State Fair.