Fillable MN TITLE VI COMPLAINT FORM (Metropolitan Transportation Authority)

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MN TITLE VI COMPLAINT FORM (Metropolitan Transportation Authority)

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________________________________________________
MN
Department of Equal Employment Opportunity and Diversity
130 Livingston Street, 3
rd
Floor
Brooklyn, New York 11201
TITLE VI COMPLAINT FORM
MTA New York City Transit (“NYCT”) is committed to providing non-discriminatory service to ensure that no person is excluded
from participation in, or denied the benets of, or subjected to discrimination in the receipt of its services on the basis of race,
color, or national origin as protected by Title VI of the Civil Rights Act of 1964 (“Title VI”).
If you feel that you have been discriminated against, please provide the following necessary information in order to facilitate the
processing of your complaint. If assistance is required to complete the form, of if you have any questions, please do not hesitate
to call Joel C. Andrews, Vice President, at (718) 694-1730. Once completed, return a signed and dated copy to:
MTA NYCT Department of Equal Employment Opportunity and Diversity
130 Livingston Street, 3
rd
Floor
Brooklyn, New York 11201
To protect your rights, your complaint must be led within 180 days following the date of the alleged discrimination. Failure to
le within 180 days may result in the dismissal of the complaint.
[ For Ofcial Use Only ]
Complaint No:
_____________________________________________________
Section I: Complaint Information (please print)
Name: _________________________________________________
Address ________________________________________________
Telephone (Home): ________________________________________
Telephone (Work): ________________________________________
Section II: Person Discriminated (other than Complainant)
E-mail: ______________________________
Race, Gender: ________________________
Accessible Format Requirement:
Large Print Audio Tape
TDD Other (specify) ______________
Are you ling this complaint on your own behalf?
Yes (if Yes, go to Section III) No
If not, please supply the name and relationship of the person for who you are ling the complaint:
Name: ___________________________________ Relationship: ________________________________
Please explain why you have led for a third-party: ____________________________________________________________
Please conrm that you have obtained the permission of the aggrieved party if you are ling on their behalf:
Yes No
Section III: Complaint Information
I believe the discrimination I experienced was based on: (check all that apply)
Race Color National Origin
Date of the alleged discrimination (month, day, year): ____________________________ Time: _____________________________
Location: _____________________________________________________________________________________________
233_18
Page 1 of 2
_________________________________________________ ___________________________________________
Section III: Complaint Information (continued)
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. If more space is needed, attach additional sheets of paper.
* You may attach any written materials or other information you think is relevant to your complaint, i.e., copy (or serial number)
of MetroCard used on the day of the incident.
Have you previously led a Title VI complaint with this agency?
Yes No
If yes, please explain: ___________________________________________________________________________
Have you led this complaint with any other federal, state, local agency, or within any federal or state court? Yes No
If yes, please check all that apply:
Federal Agency Federal Court State Agency State Court Local Agency
Please provide information about a contact person at the agency/court where the complaint was led.
Name: _______________________________________________________
Address: _____________________________________________________
_____________________________________________________
Telephone: ___________________________________________________
In addition to your right to le a complaint with NYCT, you have the right to le a Title VI complaint with the Federal Transit
Administration, Ofce of Civil Rights, Attention: Complaint Team, East Building 5
th
Floor-TCR, 1200 New Jersey Avenue, SE,
Washington, DC 20590. However, please be advised that if you le a complaint with any court or administrative agency, such
as the United States Equal Employment Opportunity Commission (“EEOC”), the New York State Division of Human Rights
(“NYSDHR”), or any other external forum, MTA NYCT Department of EEO and Diversity will administratively close your case
and refer the matter to the NYCT’s Law Department for handling.
I afrm that I have read the above charge and that it is true to the best of my knowledge, information, and belief.
Complainant’s Signature Date
Rev. 12/2016 Page 2 of 2
233_18
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MN TITLE VI COMPLAINT FORM (Metropolitan Transportation Authority)

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Completed 11 June 2021

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