Trolleys Inc - ADA_Title VI Complaint Form

Section I
Full Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Telephone (Home/Cell)
Telephone (Work)
E Mail Address
example@example.com
Accessible Format Requirements?

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Section II
Are you filing this complaint on your own behalf?

YesNo
Please supply the name and relationship of the person for whom you are complaining
Please explain why you have filed for a third party
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

YesNo
Section III
I believe the discrimination I experienced was based on (check all that apply):

RaceColorNational OriginDisability
Date of Alleged Discrimination (Month, Day, Year)

MonthDayYear
Date
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.
Section IV
Have you previously filed a Title VI or ADA complaint with this agency?

YesNo
Section V
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

YesNo
Check all that apply:

Federal AgencyState AgencyLocal AgencyFederal CourtState CourtOther
Name of Federal Agency
Name of State Agency
Name of Local Agency
Location of Federal Court
Location of State Court
Other place of filing
Please provide information about a contact person at the agency/court where the complaint was filed.
Name
Title
Agency
Address

Street Address

Street Address Line 2

CityState

Zip Code
Telephone
Section VI
Name of agency complaint is against
Contact person
Title
Telephone number
You may attach any written materials or other information that you think is relevant to your complaint.

Signature and date required below
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Date*

MonthDayYear
Date
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Section I

Section II

Section III

Section IV

Section V

Section VI