Complainant's Name
Email:
Address
City
State Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington District of Columbia West Virginia Wisconsin Wyoming
Zip Code
Telephone# Home
Telephone# Work
Telephone# Cell
Person Discriminated Against (if someone other than Complainant)
Name of Person Discriminated Against (other than Complainant)
Address of Person Discriminated Against (if someone other than Complainant)
City (if someone other than complainant)
State (if someone other than complainant) Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington District of Columbia West Virginia Wisconsin Wyoming
Zip Code (if other than complainant)
Telephone# Home (if other than complainant)
Telephone# Work (if other than complainant)
Telephone# Cell (if other than complainant)
Upon what premise is your discrimination complaint based? (check all that apply)
Date of alleged discrimination or alleged violation (or date range if this took place more than once):
Describe the alleged discrimination or alleged violation. Explain what occurred and who you believe was responsible.
Where did the incident take place? Please provide location, time, bus number etc.
Witnesses? Please provide their contact information.
Name of Witness 1
Address of Witness 1
City of Witness 1
State of Witness 1 Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington District of Columbia West Virginia Wisconsin Wyoming
Zip Code of Witness 1
Telephone# Cell Witness 1
Telephone# Home Witness 1
Telephone# Work Witness 1
Name of Witness 2
Address of of Witness 2
City of Witness 2
Zip Code of Witness 2
State of Witness 2 Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington District of Columbia West Virginia Wisconsin Wyoming
Telephone# Home Witness 2
Telephone# Work Witness 2
Telephone# Cell Witness 2
How can this complaint be resolved (how can the problem be corrected)?
Optional Information If applicable, name and title of person(s) who allegedly discriminated against you:
Is this activity still on-going?
Did you file this complaint with another federal, state or local agency, or with a federal or state court? (Check the appropriate space)
If your answers is YES check each agency with which a complaint was filed:
Please provide contact information for the agency you also filed the complaint with:
Date Filed
If you need any special accommodations for communication regarding this complaint, please specify which alternative format you require.
Special Accommodations Clarification (specify font size, specify sign language, specify specific language)
Sign the complaint in space below.
Complainant's Signature
Attachments: