Fort Bend County Public Transportation Department

Title VI Complaint Form

Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” The Fort Bend County Public Transportation Department is committed to a policy of non-discrimination in the conduct of its business, including the responsibility to deliver equitable and accessible public transportation services.

Any person who feels he or she may have been discriminated against is encouraged to report such a violation to the Fort Bend County Public Transportation Department within 180 days of the alleged discrimination.

The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please let us know by telephone (281) 633-7433 or by email at Transit@fortbendcountytx.gov. Complete and return this form to Fort Bend County Public Transportation Department, Attention Assistant Director of Public Transportation, 3737 Bamore Rd. Rosenberg, Texas 77471 or fax to (281) 243-6710.

1.Complainant’s Name ________________________________________________

2.Address___________________________________________________________

3.City, State and Zip Code______________________________________________

4.Telephone Number______________________(alternate)____________________

5.Email Address______________________________________________________

6.Person discriminated against (if someone other than the complainant)

Name_____________________________________________________________

Address___________________________________________________________

City, State and Zip Code______________________________________________

Please explain your relationship to this person ____________________________

7.Which of the following best describes the reason you believe the discrimination took place? Was it because of your:

a.Race/Color/Ethnicity___________

b.National Origin __________

8.The date in which the alleged discrimination take place? _______________

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9.In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible. Please use the back of this form if additional space is required.

10.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 agency	____ State court
____ Local agency

11.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 __________________________________________________

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

_____________________________	______________
Complainant’s Signature	Date

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