Title VI Complaint Form
Broward County Board of County Commissioners Transportation Department
COMPLAINT OF TITLE VI DISCRIMINATION
Broward County Transit, as a recipient of federal financial assistance, is required to ensure that its transit service and related benefits are distributed in a manner consistent with Title VI of the Civil Rights Acts of 1964, as amended.
Any person who believes that he or she, individually, or as a member of any specific class of persons, has been subjected to discrimination under Title VI, on the basis of race, color, or national origin, may file a written complaint with Broward County Transit.
We are asking for the following information to assist us in processing your complaint. If you need help in completing this form, please contact us at (954) 357-8481 or TTY: (954) 357-8302.
NOTE: Alternate means of filing complaint, such as personal interviews or a tape recording of the complaint, will be made available for persons with disabilities upon request.
1. Complainant Name: _______________________________________
Street Address: _____________________________________________
City, State, Zip Code: _______________________________________
Telephone: _______________________________________
Email Address: _______________________________________
2. Person you believe discriminated against you (if known):
Name: _______________________________________
3. Location of incident: _______________________________________
4. Are you represented by an attorney for this complaint
Yes_______ No______
If yes, please complete the following:
Attorney's Name: _______________________________________
Street Address: _______________________________________
City, State, Zip Code: _______________________________________
Telephone: _______________________________________
5. Which of the following best describes the reason you believe the discrimination took place? Please circle.
o Race
o Color
o National Origin
o Sex
o Income Status
o Age
o Disability
o Retaliation
o Sexual Orientation
o Political Affiliation
o Marital Status
6. Date(s) of the alleged discrimination: _________________________________
7. In the space below, please describe the alleged discrimination. Explain what happened and who you believe was responsible. (Include bus number, route number, name of transit employee(s) involved in the incident, date, location, and time of the incident, if applicable.) Attach additional sheet if necessary.
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8. Have you filed a complaint of the alleged discrimination with a federal, state, or local agency; or with a state or federal court?
Yes______ No______
If yes, check all that apply:
Federal_______ Federal Court_______
State _______ State Court _______ Local Court _______
Please provide the name of the Agency where you filed your complaint.
Agency Name: ______________________________________________
Contact Person: _____________________________________________
Complainant Signature __________________________________
Date of Signature ______________________
You may attach any additional information you think is relevant to your complaint.
Submit your signed complaint and any attachments to:
Broward County Transit
Attention: Transit Manager – Compliance
1 North University Drive, Suite 3100A, Box 306
Plantation, FL 33324
BCTD_TitleVIComplaints@broward.org
