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 Title VI Complaint Form

  

LANGUAGE TRANSLATION SERVICE AVAILABLE
NOTE: If you require this Title VI Complaint Form to be translated into another language, click on the top right corner of the web page and select the appropriate language for your translation.


SERVICO DE TRADUCCIÓN LENGUA DISPONIBLE
NOTA: Si usted require de este Formulario de Queja del Titulo VI de ser traducido a otro idoma, por favor haga clic en la esquina superior derecha de esta pàgina web y seleccionar el idioma

LANG TRADIKSYON SÈVIS KI DISPONIB
REMAK:  Si w mande pou s a Tit VI Fòm Plent dwe tradui nan yon lòt lang, tanpri klike sou nan kwen paj sa a web tèt dwat epi chwazi lang ki apwopriye a pou tradiksyon ou.


Broward County Board of County Commissioners Transportation Department​

COMPLAINT OF ADA and 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 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.

    • ​Race 
    • Color 
    • National Origin 
    • Sex 
    • Income Status 
    • Age
    • Disability 
    • Retaliation 
    • Sexual Orientation 
    • Political Affiliation 
    • 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.

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________

    __________________________________________________________________​

  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 Division
Attention: Transit Manager – Compliance
1 North University Drive, Suite 3100A, Box 306
Plantation, FL 33324​
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