Fill this in on screen, then print, sign and date it. Return the signed copy to the address at the end of the form.

Blank Official PDF

Appendix F

Title VI Complaint Form

Section I:

Accessible Format Requirements?

Section II:

Are you filing this complaint on your own behalf?

*If you answered "yes" to this question, go to Section III.

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Section III:

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

Section IV

Have you previously filed a Title VI complaint with this agency?

Section V

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?
If yes, check all that apply:

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

Section VI

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

Signature and date required below

Signature

Date

If information is needed in another language, contact 740-342-2810.

Please submit this form to

Perry County Transit
Chief of Staff
499 N. State Street, New Lexington, Ohio 43764
740-342-2810
Leslie.Finck@perrycountyohio.gov