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File A Transportation ComplaintEdwards.Sam2021-07-21T09:19:52-04:00

Section I

Name *

First

Last

Phone

Email *

Accessible Format Requirements?

Large Print
Audio Tape
TDD
Other

Section II

Are your filing this complaint on your own behalf? (copy)

Yes
No

If Yes, go to Section III

If no, what is the name of the person for whom you are filing this complaint?

What is your relationship with this individual?

Please explain why you have filed for a third party.

Please confirm that you have obtained permission of the aggrieved party to file on their behalf.

Yes
No

Section III

I believe the discrimination I experienced was based on (Check all that apply):

Race
Color
National Origin

Date of alleged discrimination

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. *

Section IV

Have you previously filed a Title VI complaint with Orange Country Adult Achievement Center?

Yes
No

Section V

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? (copy)

Yes
No

If yes, check all that apply:

Federal Agency
Federal Court
State Agency
Local Agency

If yes, provide information about a contact person at the agency/court where the complaint was filed.

Name

Title

Email *

Phone

Phone

Address

Section VI

Name of Transit Agency complaint is against

Contact Person

Agency

You may attach any additional materials or other information that you think is relevant to your complaint.

Click or drag a file to this area to upload.

Date / Time

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