Title VI Complaint Form | South Central Transit Network

Transit Title VI Complaint Form

PART I - COMPLAINANT INFORMATION

Name *

Address *

Address Line 1

City

State

Zip Code

Phone *

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PART II - BASIS OF DISCRIMINATION

Check all appropriate boxes. *

Race
Color
National Origin

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PART III - PARTICULARS OF DISCRIMINATION

Include names, dates, places and incidents involved in the complaint. *

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PART IV - REMEDY REQUESTED

State the specific remedy sought to resolve the issue(s). *

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PART V - VERIFICATION

Signature *

Date *

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