About RCTA

Title VI Complaint Form

Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” Note: The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please let us know.

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone Number (Main)(Required)

Telephone Number (Alt)

Email(Required)

Person discriminated against (if someone other than the complainant)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Which of the following best describes the reason you believe the discrimination took place? Was it because of your:(Required)

What date did the alleged discrimination take place?(Required)

What time did the alleged discrimination take place?(Required)

In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.(Required)

Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?(Required)

If yes, 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 filed.

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Electronic Signature

Electronic Signature(Required)

Please type your First and Last Name

Date(Required)

I understand that checking this box constitutes a legal signature confirming that I acknowledge the truthfulness of the information provided.(Required)

I agree.

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About RCTA

Title VI Complaint Form

Electronic Signature

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