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:

 

Title VI / ADA Coordinator
City of New Castle

227 North Main Street

New Castle, IN   47362

 

 

 

Please print clearly:

Section I:

Name:

Address:

Telephone (Home):

Telephone (Work):

Electronic Mail Address:

Accessible Format Requirements?

Large Print

 

Audio Tape

 

TDD

 

Other

 

Section II:

Are you filing this complaint on your own behalf?

Yes*

No

*If you answered "yes" to this question, go to Section III.

If you answered no to this question, please supply the name and relationship of the person for whom you are submitting this form:

 

Please explain why you have filed for a third party:

 

 

 

 

 

 

 

 

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Yes

No

Section III:

 

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

Have you previously filed a Title VI complaint with this agency?

Yes

No

Section V

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

Please provide information about a contact person at the agency/court where the complaint was filed.   

Name of Contact person:

Title:

Agency:

Address:

Telephone:

Section VI

Name of agency complaint is against:

Contact person:

Title:

Telephone number:

 

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:

Title VI / ADA Coordinator
City of New Castle

227 North Main Street

New Castle, IN   47362