Title VI Complaint Form

I believe I was excluded from participation, denied the benefits of or was subjected to discrimination by Pace Suburban Bus, which receives federal financial assistance. I believe Pace’s actions violate Title VI of the 1964 Civil Rights Act.

Background Information

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Telephone #

Additional Telephone #

Email Address:

VIOLATION – Please provide information regarding the violation:

I BELIEVED I WAS DISCRIMINATED AGAINST BASED ON (CHECK THE APPROPRIATE CATEGORY) :

RACE

COLOR

NATIONAL ORIGIN

Date of Discrimination:

In your own words, describe the alleged discrimination. Explain what happened, and who you believe was responsible.

Have you filed this complaint with any other federal, state or local agency; or with any federal or state court (please check one)

If YES, please select the appropriate agency or court, and include the requested identifying information

Illinois Department of Human Rights (IDHR)

Date filed:

Complaint Number:

UNITED STATES DISTRICT COURT

District:

Date filed:

Court Number:

STATE COURT

County:

Date filed:

Court Number:

OTHER

Date filed:

Case Number:

Additional Information

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

One file only.
512 MB limit.
Allowed types: gif, jpg, png, bmp, pdf, doc, docx, avi, mov, mp3, wav.

Signature Acknowledgment

By checking this box, I attest that the above information is correct and true to the best of my knowledge.

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