Title VI Complaint Form
"No person in the United States shall, on the grounds 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."

If you feel that you have been discriminated against in the provision of transportation services, please provide the following information to assist us in processing your complaint.  Should you require any assistance in completing this form or need information in an alternate format, contact us.
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Email *
1.  Complainant's Name:
a.  Address:
b.  City/State/ZIP Code:
c.  Phone Number:
d.  Email Address:
2.  Do you prefer to be contacted via this email address?
3.  Are you filing this complaint on your own behalf?
4.  If you answered NO to the previous question, please complete the following:
a.  Name of person filing complaint:
b.  Address:
c.  City/State/ZIP Code:
d.  Phone Number:
e.  Email Address:
Do you prefer to be contacted via this email address?
5.  What is your relationship to the person for whom you are filing the complaint?
6.  Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
7.  I believe that the discrimination I experienced was based on (check all that apply):
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8.  Date of alleged discrimination (Month/Day/Year):
MM
/
DD
/
YYYY
9.  Where did the alleged discrimination take place?
10.  Explain as clearly as possible what happened and why you believe you were discriminated against.  Describe all of the people involved.  Include the name and contact information of the person(s) who discriminate against you, if known.
11.  List witnesses' names and phone numbers/contact information, if known.
12.  What type of corrective action would you like?
13.  Have you filed a complaint with any other federal, state or local agency or with any federal or state court?
14. A complaint has been filed with:
15.  Please provide information about a contact person at the agency/court where the complaint was filed.
Any written materials or other information that you think is relevant to your complaint can be emailed to abiddix@gateway-services.org
Please type your name ("signature") and date.
If you completed these questions on behalf of a complainant, please type your name ("signature") and date.
A copy of your responses will be emailed to the address you provided.
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