KCAPTA Title VI Compaint Form-Fillable English

KINGS COUNTY AREA PUBLIC TRANSIT AGENCY
TITLE VI COMPLAINT FORM
Name: _______________________________________________________________________
Address: ______________________________________________________________________
City: ________________________________ State: ________ Zip Code: __________________
Home Telephone No: ________________________
Work Telephone No: _________________________
Were you discriminated against because of:
[ ] Race
[ ] National Origin
[ ] Color
[ ] Other
Date of Alleged Incident: __________________________________________________
Explain as clearly as possible what happened and how you were discriminated against. Indicate who was
involved. Be sure to include the names and contact information of any witnesses. If more space is needed
please use the back of the form.
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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 court
_____ Local agency
_____ State agency
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 _______________________________________________________
Please sign below. You may attach any written materials or other information that you think is relevant to
your complaint.
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Signature
Please mail this form to:
KCAPTA
Title VI Coordinator
610 W. 7th Street
Hanford, CA 93230
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Date