Title VI Complaint Form

Complainant's Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone (Home)*

Area CodePhone Number
Telephone (Work)

Area CodePhone Number
Person(s) discriminated against, if different from above:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone (Home)

Area CodePhone Number
Telephone (Work)

Area CodePhone Number
Name of agency, department or program that you believe discriminated against you:
Agency or department*
Name of individual*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I believe the discrimination I experienced was based on (check all that apply):*
Date of Alleged Discrimination (Month, Day, Year):

MonthDayYear
Date
In your own words, describe the alleged discrimination. Explain what happened and who you believe was responsible.*
List names and contact information of persons who may have knowledge of the alleged discrimination.*
Have you filed this complaint with any other federal, state or local agencies, or with any federal or state court?*

YesNo
Is you answered yes, please check all that apply.

Federal agencyState agencyLocal agencyFederal courtState court
Provide information about a contact person at the agency/court where the complaint was filed.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please sign and date this complaint form below. You may attach any written materials or other supporting information that you think is relevant to your complaint.

Important: The complaint will not be accepted if it has not been signed.
Complainant Signature*

Clear
Complainant's Name:*

First NameLast Name
Date*

MonthDayYear
If you have additional documents you would like to include, please attach them here:

Upload a File

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FTA Office of Civil Rights, Attention: Title VI Program Coordinator, East Building, 5th Floor-TCR, 1200 New Jersey Ave., SE, Washington, DC 20590.
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