Title VI Complaint

Greater Dayton RTA is committed to ensuring that no person is excluded from participation in or denied the benefits of its services on the basis of race, color or national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days from the date of the alleged discrimination.

The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact the Title VI Coordinator by calling (937) 425-8574. The completed form must be returned to Greater Dayton RTA Office of Civil Rights, Title VI Coordinator, 600 Longworth Street, Dayton OH 45402.

Name

Phone

Address

City

State

ZIP Code

Alt Phone

Person(s) 2 discriminated against (if someone other than complainant):

Address

City

State

ZIP Code

Which of the following best describes the reason for the alleged discrimination took place?

Race

Color

National Origin (Limited English Proficiency)

Date of Incident

Please describe the alleged incident of discrimination. Provide the names and title of all GDRTA employees involved if available. Explain what happened and whom you believe was responsible. Incident description

Have you filed a complaint with any other federal, state or local agencies?

Yes

No

I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.

Complainant's Signature (Name)

test

I-75 South Wagner Ford Exit

Layover @ Kroger

3N Layover

Masonite temporary stop

2 West Weather Detour

Title VI Complaint