Title VI - Complaint Form
TITLE VI COMPLAINT FORM
Title VI of the 1964 Civil Rights Act requires that "No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." If you feel you have been discriminated against in transit services, please provide the following information in order to assist us in processing your complaint and sent it to:
201 S. 25th Street
New Castle, IN 47362
Please print clearly:
Section I: |
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Name: |
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Address: |
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Telephone (Home): |
Telephone (Work): |
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Electronic Mail Address: |
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Accessible Format Requirements? |
Large Print |
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Audio Tape |
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TDD |
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Other |
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Section II: |
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Are you filing this complaint on your own behalf? |
Yes* |
No |
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*If you answered "yes" to this question, go to Section III. |
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If you answered no to this question, please supply the name and relationship of the person for whom you are submitting this form: |
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Please explain why you have filed for a third party: |
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Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. |
Yes |
No |
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Section III: |
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I believe the discrimination I experienced was based on (check all that apply): [ ] Race [ ] Color [ ] National Origin [ ] Sex [ ] Age [ ] Disability [ ] Low Income Date of Alleged Discrimination (Month, Day, Year): __________ Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known). If more space is needed, please use the back of this form. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ |
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Please list names and phone numbers of any and all witnesses to the incident. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ |
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What type of corrective action would you like to see taken by the City? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ |
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Section IV |
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Have you previously filed a Title VI complaint with this agency? |
Yes |
No |
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Section V |
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Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? [ ] Yes [ ] No If yes, check all that apply: [ ] Federal Agency [ ] Federal Court [ ] State Agency [ ] State Court [ ] Local Agency |
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Please provide information about a contact person at the agency/court where the complaint was filed. |
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Name of Contact person: |
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Title: |
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Agency: |
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Address: |
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Telephone: |
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Section VI |
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Name of agency complaint is against: |
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Contact person: |
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Title: |
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Telephone number: |
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You may attach any written materials or other information that you think is relevant to your complaint.
Signature and date required below
_____________________________________ ________________________
Signature Date
Please submit this form in person at the address below, or mail this form to:
201 S. 25th Street
New Castle, IN 47362