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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.”
The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please let us know. If information is needed in another language, then contact (903)872-2405 or 1(800)834-1924. SI NECESITA INFORMACION EN OTRO IDIOMA LLAME (903)872-2405 o 1(800)834-1924. Complete and return this form to: Community Transit Services, Title VI Complaint Coordinator, P.O. Box 612, Corsicana, Texas 75151-0612. You may also fax a complaint form to 1(903)875-3779 or scan and e-mail to [email protected].
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Name: ________________________________ Address: ________________________________
City: ___________________________ State: _______ Zip Code: ___________
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If so, list agency/ agencies and contact information below
Address: ____________________________ City: ________________ State: ______ Zip Code: _______
Address: ____________________________ City: ________________ State: ______ Zip Code: _______
Complainants Signature: _____________________________________ Date: ______________
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Print or Type Name of Complainant
Date Received: _______________________
Received By: _______________________