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Placer County TART Title VI Complaint Form

Title VI of the Civil Rights Act of 1964 states 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.” If you believe you have been discriminated against, please provide the following information in order to assist Placer County in processing your complaint.

SECTION 1 (Please print clearly):

Name: ______________________________________________________________________________________

Address:______________________________________________________________________________________

City, State, Zip Code:______________________________________________________________________________________

Telephone Number: ______________________(Home) ______________________(Work)

Accessible format requirements? ____(Large print)____(Audio)_____(TDD)_____(Other)

 

SECTION 2

Are you filing this complaint on your own behalf? _____(Yes)_____(No)
If you answered yes to this question, go to Section 3.

If not, please supply the name and relationship of the person for whom you are complaining:

Name: ______________________________________Relationship:________________________________

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 the third party. _____(Yes)_____(No)

 

SECTION 3

I believe the discrimination I experienced was based on (check all that apply): _______ Race _______ Color_______ National Origin

Date, Time and Place of Occurrence: ______________________________________________________________________________

Name (s) and Title(s) of the person (s) who I believe discriminated against me: ________________________________________________________________________________________________________

________________________________________________________________________________________________________

The action or decision which caused me to believe I was discriminated against is as follows: (Please include a description of what happened and how your benefits were denied, delayed or affected):

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

 

Please list any and all witnesses’ names and phone numbers (if available):

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

What type of corrective action would you like to see taken?________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

 

SECTION 4

Have you previously filed a Title VI complaint with this agency? _____(Yes) _____(No)

 

SECTION 5

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court?

______(Yes) _____(No)

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.

Name:________________________________ Title:_______________________________

Agency:______________________________________________________________________

Address:______________________________________________________________________

Telephone Number:______________________________________________________________________

You may attach any written materials or other information that you think is relevant to your complaint. I believe the above information is true and correct to the best of my knowledge. Signature and date required below:

Signature:______________________________________________________________________

Printed Name:______________________________________________________________________

Date:______________________________________________________________________

Please submit this form in person at the address below or mail this form to:

Placer County Department of Public Works
3091 County Center Drive, Suite 220
Auburn, CA 95603