Livermore Amador Valley Transit Authority

Title VI Complaint Form

Title VI of the 1964 Civil Rights Act requires 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."

Note: The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please let us know.
Complete and return this form to:  Title VI Coordinator, Livermore Amador Valley Transit Authority, 1361 Rutan Drive, Suite 100, Livermore, CA 94551.  

1. Complainant's Name ________________________________________________  

2. Address___________________________________________________________

3. City, State and Zip Code______________________________________________

4. Telephone Number (home) _________________(business)__________________

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

Name_____________________________________________________________

Address___________________________________________________________

City, State and Zip Code______________________________________________

6. Which of the following best describes the reason you believe the discrimination took place? Was it because of your:
   a. Race/Color______________________________
   b. National Origin__________________________


7. What date did the alleged discrimination take place? _______________________


8. In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.  Please use the back of this form if additional space is required. __________________________________________________________________
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9. 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


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

Name_____________________________________________________________

Address___________________________________________________________

City, State, and Zip Code _____________________________________________

Telephone Number __________________________________________________

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


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Complainant's Signature 	                                  Date