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Street Type - Road, Street, Avenue Etc.
Check all that apply: Race, Color, National Origin or Other
If other, please explain.
Please indicate your race/color if that is the basis of your complaint
Please indicate your national origin if that is the basis of your complaint
Where did this incident occur?
When did this incident occur? Please Insert the Date and Time.
Name, position, or description of individual(s) who allegedly subjected you to discrimination
Did anyone else witness the incident? Please Select Yes or No.
List witnesses (name, address, phone numbers if available)
Did you file this complaint with the Federal Transit Administration? Please Select Yes or No.
When did you file the complaint with the FTA? Please Select a Date and Time.
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.
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