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Title VI Complaint Form

  1. First Name

  2. Last Name

  3. Street Number

  4. Street Name

  5. Street Type - Road, Street, Avenue Etc.

  6. Apt #

  7. City

  8. State

  9. Zip Code

  10. Phone Number

  11. Email Address

  12. Type of Discrimination*

    Check all that apply: Race, Color, National Origin or Other

  13. If other, please explain.

  14. Please indicate your race/color if that is the basis of your complaint

  15. Please indicate your national origin if that is the basis of your complaint

  16. Where did this incident occur?

  17. When did this incident occur? Please Insert the Date and Time.

  18. Name, position, or description of individual(s) who allegedly subjected you to discrimination

  19. Did anyone else witness the incident?

    Did anyone else witness the incident? Please Select Yes or No.

  20. List witnesses (name, address, phone numbers if available)

  21. Did you file this complaint with the Federal Transit Administration?

    Did you file this complaint with the Federal Transit Administration? Please Select Yes or No.

  22. When did you file the complaint with the FTA? Please Select a Date and Time.

  23. I hearby swear/affirm that the information I have provided in this Title VI complaint is true and correct to the best of my knowledge, information and belief*

    I hearby swear/affirm that the information I have provided in this Title VI complaint is true and correct to the best of my knowledge, information and belief. Please select Agree or Do Not Agree.

  24. Leave This Blank:

  25. This field is not part of the form submission.