Title VI and ADA Complaint Form

Section I:

Your Name:

Address:

Telephone (Home):

Telephone (Work/Mobile):

Email Address:

Accessible Format Requirements?

Large Print

Audio Tape

TDD

Other

Section II:

Are you filing this complaint on your own behalf?

Yes*

No

*If you answered “yes” to this question, go to Section III.

If not, please supply the name and relationship of the person for whom you are complaining:

Please explain why you have filed for a third party:

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Yes

No

Section III:

I believe the discrimination I experienced was based on (check all that apply):

☐ Race                    ☐ Color                 ☐ National Origin                              ☐ Disability

Date of Alleged Discrimination (Month, Day, Year): _____________

TRA Group, Inc. complaint is against: ______________________________________________

Location of where the alleged discrimination occurred:- _____________________________________

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. If more space is needed, please attach additional pages.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Section IV

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:                                                    

Provide information for the contact person at the agency/court where the complaint was filed.    

Name and Title:

Agency:

Address:

Telephone: