Form Center

2. First Name*
   First Name
3. Last Name
   Last Name
5. Street Number
   Street Number
6. Street Name
   Street Name
7. Street Type
   Street Type - Road, Street, Avenue Etc.
8. Apt #
   Apt #
10. City
    City
11. State
    State
12. Zip Code
    Zip Code
14. Phone Number
    Phone Number
15. Email Address
    Email Address
17. Type of Discrimination*

    1. Race
    2. Color
    3. National Origin
    4. Other

    Check all that apply: Race, Color, National Origin or Other
18. If other, please explain.
    If other, please explain.
20. Please indicate your race/color if that is the basis of your complaint
    Please indicate your race/color if that is the basis of your complaint
21. Please indicate your national origin if that is the basis of your complaint
    Please indicate your national origin if that is the basis of your complaint
23. Where did this incident occur?
    Where did this incident occur?
24. When did this incident occur?
    When did this incident occur?

    When did this incident occur?
    When did this incident occur? Please Insert the Date and Time.
26. Name, position, or description of individual(s) who allegedly subjected you to discrimination
    Name, position, or description of individual(s) who allegedly subjected you to discrimination
28. Briefly describe the incident*
30. Did anyone else witness the incident?

    1. Yes
    2. No

    Did anyone else witness the incident? Please Select Yes or No.
31. List witnesses (name, address, phone numbers if available)
    List witnesses (name, address, phone numbers if available)
33. Did you file this complaint with the Federal Transit Administration?

    1. Yes
    2. No

    Did you file this complaint with the Federal Transit Administration? Please Select Yes or No.
34. When did you file the complaint with the FTA?
    When did you file the complaint with the FTA?

    When did you file the complaint with the FTA?
    When did you file the complaint with the FTA? Please Select a Date and Time.
36. I hearby swear/affirm that the information I have provided in this Title VI complaint is true and correct to the best of my knowledge, information and belief*

    1. Agree
    2. Do not agree

    I hearby swear/affirm that the information I have provided in this Title VI complaint is true and correct to the best of my knowledge, information and belief. Please select Agree or Do Not Agree.
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field