(NAME OF Transit Agency) TRANSIT TITLE VI COMPLAINT FORM (Print all items legibly.) PART I - COMPLAINANT INFORMATION Name Telephone Street Address/P.O. Box Email Address City State Zip Code [Check all appropriate box(es).] PART II - CAUSE OF DISCRIMINATION BASED ON □Race □Color □National Origin (Include names, dates, places, and incidents involved in the PART III - THE PARTICULARS ARE: complaint.) [If additional space is needed, attach extra sheet(s).] [State the specific remedy sought to resolve the issues(s).] PART IV - REMEDY SOUGHT PART V - VERIFICATION Complainant’s Signature _______________________________ Date ____________________ Instructions GENERAL
(NAME OF Transit Agency) TRANSIT TITLE VI COMPLAINT FORM PART I - COMPLAINANT INFORMATION (Print all items legibly.) Name Telephone Street Address/P.O. Box Email Address City State Zip Code PART II - CAUSE OF DISCRIMINATION BASED ON [Check all appropriate box(es).] □Race □Color □National Origin PART III - THE PARTICULARS ARE: (Include names, dates, places, and incidents involved in the complaint.) [If additional space is needed, attach extra sheet(s).] PART IV - REMEDY SOUGHT [State the specific remedy sought to resolve the issues(s).] PART V - VERIFICATION Complainant’s Signature _______________________________ Date ____________________ Instructions GENERAL
TitleVIComplaintFormTemplate5-2016.docx