Person(s) discriminated against, if different from above:
Name of agency, department or program that you believe discriminated against you:
Provide information about a contact person at the agency/court where the complaint was filed.
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.
FTA Office of Civil Rights, Attention: Title VI Program Coordinator, East Building, 5th Floor-TCR, 1200 New Jersey Ave., SE, Washington, DC 20590.