Title VI Civil Rights Act Complaint Form
Americans with Disabilities Act (ADA) Discrimination Complaint Form
Street Address Line 2
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Accessible format Requirements?
Are you Filing This complaint on your own behalf? (If you answered "yes" to this question, go to Section III)
If you answered "yes" to the above question, go to Section III. If you answered "no", please supply the name and relationship of the person for whom you are complaining.
Please explain why you have filed for a third party:
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party:
Please identify the area you believe you were discriminated against.
Title VI: Race
Title VI: Ethnicity
Title VI: Color
Date of Alleged Discrimination (Month, Day, Year):
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. Any details related to time of day, route, vehicle ID or driver name.
Have you previously filed a discrimination Complaint with this agency?
If yes, please provide any reference information regarding your previous complaint.
Have you filed this complaint with any other Federal, State, or locacl agency, or with any Federal or State court?
If yes, check all that apply:
Please provide information about a contact person at the agency/court where the complaint was filed. Name, Title, Agency, Address, Telephone.
Name of agency complaint is against
Name of person complaint is against:
Phone number (if available)
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