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Title VI Complaint Form
Broward County > Broward County Transit > Title VI Complaint Form

Broward County
Board of County Commissioners
Transportation Department

COMPLAINANT OF TITLE VI DISCRIMINATION

The Broward County Transit Division, as a recipient of federal financial assistance, is required to ensure that its transit service and related benefits are distributed in a manner consistent with Title VI of the Civil Rights Acts of 1964, as amended.

Any person who believes that he or she, individually, or as a member of any specific class of persons, has been subjected to discrimination under Title VI, on the basis of race, color, or national origin, may file a written complaint with the Broward County Transit Division.

We are asking for the following information to assist us in processing your complaint.  If you need help in completing this form, please let us know.

1. Complainant

Name: ________________________________________

Street Address: ________________________________________

City, State, Zip Code: ________________________________________

Telephone: ________________________________________

Email Address: ________________________________________


2. Person discriminated against (if someone other than the complainant).

Name: ________________________________________

Street Address: ________________________________________

City, State, Zip Code: ________________________________________

Home Tel. Number: ________________________________________
 
Business Number: ________________________________________

Email Address:  ________________________________________
 

3. Are you represented by an attorney for this complaint?

Yes ______   No ______

If yes, please complete the following:

Attorney’s Name: ________________________________________

Street Address: ________________________________________

City, State, Zip Code: ________________________________________

Telephone Number: ________________________________________


4. Which of the following best describes the reason you believe the discrimination took place?

Race ______   Color ______   National Origin ______  Sex ______   Disability ______  

Sexual Orientation ______  Political Affiliation ______  Marital Status ______   
 

5. Date of the alleged discrimination:________________________________________

6. In the space below, please describe the alleged discrimination.  Explain what happened and who you believe was responsible.  (Include bus number, route number, name of transit employee(s) involved in the incident, date, location, and time of incident, if applicable.)  Attach additional sheet if necessary.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________


7. Have you filed a complaint of the alleged discrimination with a federal, state, or local agency; or with a state or federal court?

Yes ______  No______

If yes, check all that apply:

Federal ______   Federal Court ______   State ______   State Court ______   Local ______   

Please provide the name of the Agency where you filed your complaint.

Name: ________________________________________

Contact Person: ________________________________________


8. Please sign below.  You may attach any additional information you think is relevant to your complaint.

  
_______________________________________________                __________________
Signature of Complainant                                                          Date


Submit your signed complaint and any attachments to:

Broward County Transit Division
Attention:  Compliance Manager
1 N. University Drive, Suite 3100A, Mailbox 306
Plantation, FL 33324
Telephone:   (954) 357-8481
TTY:  (954) 357-8302


LANGUAGE TRANSLATION SERVICE AVAILABLE

NOTE:  If you require this Title VI Complaint Form to be translated into another language, please click on either “Microsoft Translator” or “Google Translate” at the top right corner of this web page and select the appropriate language for your translation.


Rev. 11/29/11