(If further space is need, attach to this form) I understand that this statement of complaint will be submitted to the Handi-Wheels Director. The complaint may be the basis for review and/or investigation. Further, I sincerely and truly declare and affirm that the facts contained herein are complete, accurate, and true to the best of my knowledge and belief. Further, I declare and affirm that my statement has been made by me voluntarily without persuasion, coercion, or promise of any kind. ________________________________________________ ________________________ Signature of Complainant Date ________________________________________________ ________________________ Signature of Handi-Wheels Executive Director Date Any person who believes himself/herself or any specific class of person to be subjected to discrimination prohibited by Title VI may by himself/herself or by a representative file a written complaint either with Transportation, Inc. or the Regional Civil Rights Officer, Federal Transit Administration, 12300 W. Dakota Ave, Suite 310, Lakewood, CO 80228-2583. A complaint must be filed no later than 180 calendar days after the date of the alleged discrimination, unless the time for filing is extended by FTA.
(If further space is need, attach to this form) I understand that this statement of complaint will be submitted to the Handi-Wheels Director. The complaint may be the basis for review and/or investigation. Further, I sincerely and truly declare and affirm that the facts contained herein are complete, accurate, and true to the best of my knowledge and belief. Further, I declare and affirm that my statement has been made by me voluntarily without persuasion, coercion, or promise of any kind. ________________________________________________ ________________________ Signature of Complainant Date ________________________________________________ ________________________ Signature of Handi-Wheels Executive Director Date Any person who believes himself/herself or any specific class of person to be subjected to discrimination prohibited by Title VI may by himself/herself or by a representative file a written complaint either with Transportation, Inc. or the Regional Civil Rights Officer, Federal Transit Administration, 12300 W. Dakota Ave, Suite 310, Lakewood, CO 80228-2583. A complaint must be filed no later than 180 calendar days after the date of the alleged discrimination, unless the time for filing is extended by FTA.
Title%20VI%20Notice%20to%20the%20Public%20Revised%2010-29-2015.docx