Broward County
Board of County Commissioners
Transportation Department
COMPLAINANT OF TITLE VI DISCRIMINATION
The Broward County Transit Division, 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 the Broward County Transit Division.
We are asking for the following information to assist us in processing your complaint. If you need help in completing this form, please let us know.
1. Complainant
Name: ________________________________________
Street Address: ________________________________________
City, State, Zip Code: ________________________________________
Telephone: ________________________________________
Email Address: ________________________________________
2. Person discriminated against (if someone other than the complainant).
Name: ________________________________________
Street Address: ________________________________________
City, State, Zip Code: ________________________________________
Home Tel. Number: ________________________________________
Business Number: ________________________________________
Email Address: ________________________________________
3. 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 Number: ________________________________________
4. Which of the following best describes the reason you believe the discrimination took place?
Race ______ Color ______ National Origin ______ Sex ______ Disability ______
Sexual Orientation ______ Political Affiliation ______ Marital Status ______
5. Date of the alleged discrimination:________________________________________
6. 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 incident, if applicable.) Attach additional sheet if necessary.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7. 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 ______
Please provide the name of the Agency where you filed your complaint.
Name: ________________________________________
Contact Person: ________________________________________
8. Please sign below. You may attach any additional information you think is relevant to your complaint.
_______________________________________________ __________________
Signature of Complainant Date
Submit your signed complaint and any attachments to:
Broward County Transit Division
Attention: Compliance Manager
1 N. University Drive, Suite 3100A, Mailbox 306
Plantation, FL 33324
Telephone: (954) 357-8481
TTY: (954) 357-8302
LANGUAGE TRANSLATION SERVICE AVAILABLE
NOTE: If you require this Title VI Complaint Form to be translated into another language, please click on either “Microsoft Translator” or “Google Translate” at the top right corner of this web page and select the appropriate language for your translation.
Rev. 11/29/11