Macon-Bibb Transit Authority Title VI Discrimination Complaint Form

Macon-Bibb County Transit Authority

Title VI Discrimination Complaint Form
Today's Date*

MonthDayYear
What is Today's Date
Are you the Complainant or are you filling this form out on behalf of Complainant?

I am the Complainant.

The incident happened to me.
I am NOT the Complainant.

The incident happened to someone else and I am filling out this form on their behalf.
Your Name:*

First NameLast Name
Your Address

Street Address

Street Address Line 2

CityState

Zip Code
Best Phone Number to Reach You
Please enter a valid phone number.
Your Email Address*
example@example.com

Date of the alleged occurrence*

MonthDayYear
Date
What premise is your discrimination complaint based?*

RaceReligionNational Origin
Describe the alleged discrimination. Explain what happened and who you believe was responsible.
Where did the incident take place? Please provide location, time, bus number etc.:
We need as much information as you can provide.
How can this complaint be resolved?
How can the problem be corrected?
Please upload any files or photos supporting your complaint.

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Did you file this complaint with another federal, state, or local agency or with a federal or state court?
Did you file this complaint with another federal, state, or local agency or with a federal or state court?

Federal AgencyState AgencyFederal CourtState CourtLocal AgencyOther
Please provide contact information for the agency you also filed the complaint with
Date of Filing

MonthDayYear
Date

Any person who believes they have been aggrieved by an unlawful discriminatory practice regarding the Macon-Bibb County Transit Authority's services has a right to file a formal complaint. Any such complaint must be submitted within 180 days following the date of the alleged occurrence.

By including your electronic signature below, you certify the information is correct to the best of your ability.
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Macon-Bibb County Transit Authority