ADA/Title VI Complaint Form

This complaint should include the following information:

The complainant’s name, mailing address, telephone number, e-mail address, etc.
Describe how, when, where, and why the complainant believes he or she was discriminated against. Include the location, names, and contact information of any witnesses.
Include any additional information the complainant considers relevant to the complaint.
The complainant’s signature and date.

Any such complaint must be in writing and submitted to the GTA Title VI Coordinator within 180 days following the date of the alleged discrimination. A Title VI Civil Rights Complaint Form is available online or by calling 336-373-2634. Complaints should be addressed to: GTA Title VI Coordinator, 223 W. Meadowview Rd., Greensboro, NC 27406.

Anyone who submits a form should be aware that in accordance with the North Carolina Public Records law, found in North Carolina General Statutes Chapter 132, his or her e-mail address is considered public record.

Check all that apply:*

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Telephone Numbers

E-mail Address

example@example.com

How would you like to be contacted?

E-mailPhoneOther

Accessible Format Requirements. I need the form in the following format*

(If none needed, type N/A)

The Federal Transit Administration (FTA) Office of Civil Rights is responsible for civil rights compliance and monitoring, which includes ensuring that providers of public transportation properly abide by Title VI of the Civil Rights Act of 1964, Executive Order 12898, “Federal Actions to Address Environmental Justice in Minority Populations and Low Income Populations”, and the Department of Transportation’s Guidance to Recipients on Special Language Services to Limited English Proficient (LEP) Beneficiaries.

Are you filing this complaint on your own behalf?*

YesNo

Please provide the name and relationship of the person for whom you are filing the complaint*

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

ADA/Title VI Complaint Form

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