Complaint Form

Title VI of the Civil Rights Act of 1964 states that “No person in the United States shall on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefit of, or otherwise be subjected to discrimination in any program, service, or activity receiving federal assistance.”

This form may be used to file a complaint with the Region XII Council of Governments/Western Iowa Transit based on violations of Title VI of the Civil Rights Act of 1964. You are not required to use this form; a letter that provides the same information may be submitted to file your complaint. Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to know the act was discriminatory within 180 day period, you have 60 days after you became aware to file your complaint.

If you need assistance completing this form, please contact Matt Cleveland by phone at 712-792-9914 or via e-mail at [email protected].

Name

Date

Street Address

City

State

Zip

Phone

Individual(s) discriminated against, if different than above.

Name

Street Address

City

State

Zip

Phone

Please explain your relationship with the individual(s) indicated above

Name of agency and department or program that discriminated:

Agency or department name

Name of individual (if known)

Address (if known)

City

State

Zip

Date(s) of alleged discrimination:

Date discrimination began

Last or most recent date

ALLEGED DISCRIMINATION:

If your complaint is in regard to discrimination in the delivery of services or discrimination that involved the treatment of you by others by the agency or department indicated above, please indicate below the basis on which you believe these discriminatory actions were taken.

RaceColorNational Origin

Explain: Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and others involved in the alleged discrimination.

Note: The Region XII Council of Governments prohibits retaliation or intimidation against anyone because that individual has either taken action or participated in action to secure rights protected by policies of the agency. Please inform the person listed above if you feel you were intimidated or experience perceived retaliation in relation to filing this complaint.