Fillable Civil Rights Complaint Form (Morgan County)

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Civil Rights Complaint Form (Morgan County)

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Civil Rights Complaint Form
The Federal Transit Administration Office of Civil Rights is responsible for ensuring that
providers of public transit properly implement several civil rights laws and programs, including
Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990 (ADA), the
Disadvantaged Business Enterprise (DBE) program, and the External Equal Employment
Opportunity (EEO) program.
In the FTA complaint investigation process, we analyze the complainant's allegations for possible
deficiencies by the transit provider. If deficiencies are identified, they are presented to the transit
provider and assistance is offered to correct the inadequacies within a predetermined timeframe.
Please mail your completed form to:
Director, FTA Office of Civil Rights
East Building, 5th Floor – TCR
1200 New Jersey Ave., SE
Washington, DC 20590
If you have questions about how to prepare a complaint, you may contact our toll-free FTA
Assistance Line at 1-888-446-4511. More information about transit-related civil rights
requirements may be found on the FTA’s website at www.fta.dot.gov.
Note: Apart from the form, on separate pages, please describe your complaint. You
should include specific details such as names, dates, times, route numbers, witnesses,
and any other information that would assist us in our investigation of your allegations.
Please also provide any other documentation that is relevant to this complaint, including
any related correspondence from your transit provider.
Important: We cannot accept your complaint without a signature, so please sign on the
last page of the form after printing out.
Section I
I believe that I have been (or someone else has been) discriminated against on the basis
of:
Race / Color / National Origin
Disability
Not Applicable
Other (specify)
I believe that a public transit provider has failed to comply with the following program
requirements:
Disadvantaged Business Enterprise
External Equal Employment Opportunity
Not Applicable
Other (specify)
Section II
Name:
Street Address:
City:
Zip Code:
Telephone Numbers:
Home:
Cell:
E-Mail Address:
Accessible format requirements:
Large Print
Not Applicable
Other
Section III
Are you filing this complaint on your own behalf?
Yes
No
[If you answered “yes” to this question, go to Section IV.]
2
If not, 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:
Yes
No
Section IV
Have you previously filed a civil rights complaint with
Yes
No
FTA?
If yes, what was your FTA Complaint Number?
Have you filed this complaint with any of the following agencies?
Transit Provider
Department of Transportation
Department of Justice
Equal Employment Opportunity Commission
Other
If yes, please attach a copy of any response you received to your previous complaint.
Have you filed a lawsuit regarding this complaint?
Yes
No
If yes, please provide the case number and attach any related material.
Note: FTA encourages, but does not require, riders to first file complaints with their local
transit agencies to give them an opportunity to resolve the issue.
3
Section V
Name of public transit provider complaint is against:
Contact person
Title
Telephone number
Section VI
May we release your identity and a copy of your complaint to the transit provider?
Yes
No
Note: We may be unable to investigate your allegations without permission to release
your identity and complaint.
Please sign here:
Date:
Note: We cannot accept your complaint without a signature.
4
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Civil Rights Complaint Form (Morgan County)

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Completed 18 July 2020

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