Title VI Civil Rights Act Complaint Form
Americans with Disabilities Act (ADA) Discrimination Complaint Form
Section I:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Accessible format Requirements?
Large Print
Audio Tape
TDD
Other
Section II
Are you Filing This complaint on your own behalf? (If you answered "yes" to this question, go to Section III)
Yes*
No
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:
Yes
No
Section III
Please identify the area you believe you were discriminated against.
ADA: Disability
Title VI: Race
Title VI: Ethnicity
Title VI: Color
Other
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.
Section IV:
Have you previously filed a discrimination Complaint with this agency?
Yes
No
If yes, please provide any reference information regarding your previous complaint.
Section V
Have you filed this complaint with any other Federal, State, or locacl agency, or with any Federal or State court?
Yes
No
If yes, check all that apply:
Federal Agency:
Federal Court
State Court:
State Agency
Local Agency
Please provide information about a contact person at the agency/court where the complaint was filed. Name, Title, Agency, Address, Telephone.
Section VI
Name of agency complaint is against
Name of person complaint is against:
Title:
Location:
Phone number (if available)
If you have any attachments to upload, attach them here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: