Inclement Weather   |    Contact Us    |    Current Events   |   Intercity   |   DBE

Section I:

Name:

Address:

Telephone (Home):

Telephone (Work):

Electronic Mail Address:

Accessible Format Requirements?

Large Print

 

Audio Tape

 

 

TDD

 

Other

 

 

Section II:

Are you filling this complaint out on your own behalf?

Yes*

No

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

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

 

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 a third party.

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 (Month, Day, Year): ____________

 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.  If more space is needed, please the back of this form.

  

 

Section IV:

 

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

Yes

No

 

Section V:

 

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 the complaint was filed.

 

Name:

 

Title:

 

Agency:

 

Address:

 

Telephone:

 

Section VI:

 

Name of Agency complaint is against:

 

Contact person:

 

Title:

 

Telephone number:

 

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

Signature and date required below:

_________________________________________      __________________________

Signature                                                                               Date            

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

Sandy Valley Transportation Services, Inc.

81 Resource Court

Prestonsburg, Kentucky  41653