Title VI Complaint Form

Title VI Complaint Form

Here and There Transit

P.O. Box 146, Philippi, WV 26416

(304) 457-1818, (TDD Accessible )

Here and There Transit is committed to ensuring that no person is excluded from participation in or denied the benefits of its services on the basis of race, color or national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days from the date of the alleged discrimination.

The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact the Title VI Officer by calling (304) 457-1818 ( TDD accessible). The completed form must be returned to P.O. Box 146, Philippi, WV 26416.

Name (print): _________________________________________________________________

Mailing Address: ______________________________________________________________

______________________________________________________________________________

Phone: ________________________________ Alt Phone: _____________________________

Person(s) discriminated against (if someone other than the complainant):_______________

______________________________________________________________________________

Address, City, State & Zip: ______________________________________________________

______________________________________________________________________________

1. Which of the following best describes the reason for why the alleged discrimination took place?

_____ Race _____Color _____National Origin (Limited English Proficiency)

2. Date, time and location of Incident: _________________________________________

________________________________________________________________________

3. Please describe why you believe discrimination has occurred. Provide names of all transit system personnel involved or responsible, if available. If there are witnesses, please provide names, addresses and telephone numbers. Use the back of this form if additional space is required.

________________________________________________________________________

3. (continued)

________________________________________________________________________

4. Have you filed a complaint with any other federal, state or local agencies?

_____ Yes _____No

If yes, please list agency/agencies and contact information below (please use back of form if additional space is needed).

Agency: ________________________________________________________________

Address: _______________________________________________________________

Contact Person: _____________________________ Phone: _____________________

I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.

___________________________________________________ ________________________

Signature Date

System Use ONLY

Date Received: _____________________________________

Received By: ______________________________________