Transit Title VI Complaint Form

Instructions

 GENERAL

  1. Instructions provided within this form are not meant to be all inclusive. Any person or group(s) of persons filing external complaints of discrimination are responsible for all procedural requirements contained in the External complaints of Discrimination process.
  1. Under Title VI of the Civil Rights Act of 1964 or the related statutes and regulations, no person or groups(s) of persons shall, on the grounds of race, color, national origin; or sex, age, disability, limited English proficiency, or income status, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any and all programs, services, or activities administered by South Central Transit Network. Any person or groups(s) of persons who feel they have been discriminated against may file a complaint.
  1. Complainants must include all required information and must meet all timeframes as defined in the South Central Transit Network Complaint Procedure.
  1. Legible copies of all available pertinent documentation should be attached to this form.
  1. All inquiries should be directed to Pat Hansen, South Central Transit Network, PO Box 298, Valley City, ND 58072, (800) 472-0031.

PART I

Complete all information in this section.

PART II

Check all boxes that apply indicating the basis for the complaint.  The discrimination must be based on at least one of the listed categories under Title VI or Other Nondiscrimination Statutes/Executive Orders.

PART III

State the specific complaint in a manner that clearly identifies the issues upon which the complaint is based.

PART IV

State the minimum remedy acceptable for resolution of this complaint.

PART V

Sign and date this section to verify the information contained in Parts I through IV.

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PART I - COMPLAINANT INFORMATION

Address
_________________________________________________________

PART II - CAUSE OF DISCRIMINATION OR COMPLAINT BASED ON

[Check all appropriate box(es).]
Title VI of the Civil Rights Act of 1964
Other Nondiscrimination Statutes/Executive Orders
_________________________________________________________

PART III - PARTICULARS OF DISCRIMINATION

Click or drag a file to this area to upload.
_________________________________________________________

PART IV - REMEDY SOUGHT

_________________________________________________________

PART V - VERIFICATION

To file on paper, download the form and mail it to:  Pat Hansen, PO Box 298, Valley City, ND 58072.

TITLE VI Complaint Form with Instructions