Title VI Complaint Form

Title VI Complaint Form

    If you would prefer to complete a paper copy of the Title VI Complaint Form, please download the PDF version. Once completed, you can either drop it off at the River Valley Transit office or mail it to: River Valley Transit 1500 West 3rd St Williamsport

    Contact Information

    Accessible format requirements

    Large Print
    TDD
    Audio Tape
    Other

    Complainant Information

    Are you filing this complaint on your own behalf? *

    [group grpSelf]

    I believe the discrimination I experienced was based on: *

    Race
    Color
    National Origin

    Date of allegegd discrimination *

    Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. *

    [/group]
    [group grpOther]

    Please explain why you are filing for a third party *

    Have you obtained permission of the aggrieved party you are filing on behalf for? *

    [/group]

    Filing Information

    Have you previously filed a Title VI complaint with this agency? *

    Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? *

    [group grpAgency]

    Where have you previously filed complaints? *

    Agency Contact Information:

    [/group]

    Signature

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