Complaint Form

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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].

  1. Complainant’s Name: _______________________________________________________



  1. Address: __________________________________________________



  1. City: ______________________________ State: _________ Zip Code: _________________



  1. Telephone Number (Home): __________________________




  1. Person discriminated against (if someone other than the complainant):

Name: ________________________________ Address: ________________________________


City: ___________________________ State: _______ Zip Code: ___________


  1. Which of the following best describes the reason you believe the discrimination took place:
    Were you discriminated against because of: (check one)

    1. Race/Color: Yes ____ No____
    2. National Origin: Yes ____ No ____


  1. What date and time did the alleged discrimination take place? ___________________________


  1. Explain as clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include the names and contact information of any witnesses. Please use the back of this form if additional space is required: ____________________________________________________________________________________












  1. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court? Yes_____ No_____


If so, list agency/ agencies and contact information below


  1. Please provide information about a contact person at the agency/court where the complaint was filed.
  2. Agency: _____________________________________________ Contact Name: _________________

Address: ____________________________ City: ________________ State: ______ Zip Code: _______

  1. Agency: _____________________________________________ Contact Name: _________________

Address: ____________________________ City: ________________ State: ______ Zip Code: _______


  1. I affirm that I have read the above charge and it is true to the best of my knowledge.

Complainants Signature: _____________________________________ Date: ______________



                                                                     Print or Type Name of Complainant                                       



Date Received: _______________________


                                                                                                                               Received By:     _______________________