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Transit Title VI Complaint Form
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PART I - COMPLAINANT INFORMATION
Name
*
Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
______________________________________________________________________________________________________________________________________________________________________________
PART II - BASIS OF DISCRIMINATION
Check all appropriate boxes.
*
Race
Color
National Origin
______________________________________________________________________________________________________________________________________________________________________________
PART III - PARTICULARS OF DISCRIMINATION
Include names, dates, places and incidents involved in the complaint.
*
______________________________________________________________________________________________________________________________________________________________________________
PART IV - REMEDY REQUESTED
State the specific remedy sought to resolve the issue(s).
*
______________________________________________________________________________________________________________________________________________________________________________
PART V - VERIFICATION
Signature
*
Clear Signature
Date
*
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