Perry County Transit — Title VI Complaint Form

Title VI of the Civil Rights Act of 1964 states “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.”

Please provide the following information necessary in order to process your complaint. Assistance is available upon request.

Complete this form and mail or deliver to

Perry County Job & Family Services
Title VI Coordinator
5250 State Route 37 East
New Lexington, OH 43764

You may reach our office by calling 740-684-4565, Monday-Friday 8 a.m.- 4:30 p.m. You may email our Title VI coordinator at Leslie.Finck@jfs.ohio.gov

1. Complainant's Name

2. Address

3. Telephone Contact Number

4. Person alleged to have been discriminated against (if other than complainant)

Name

Address

5. What was the discrimination alleged to have been based on? (Tick all that apply)

a) Race/Color b) National Origin c) Limited English Proficiency

6. Date of incident when alleged discrimination occurred

Page 1 of 2

7. Describe how you were discriminated against. What happened and who was responsible? Please provide the location of the incident, bus number and line.

8. Witnesses? Please provide their contact information.

Witness names and telephone numbers
Name	Telephone number
Witness 1 name	Witness 1 telephone number
Witness 2 name	Witness 2 telephone number
Witness 3 name	Witness 3 telephone number
Witness 4 name	Witness 4 telephone number

Signature

Date

Page 2 of 2