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Dupage County Title Vi Complaint Form - Dupage County Department Of Community Services

DuPage County Title VI Complaint Form

Description: Title VI of the 1964 Civil Rights Act requires that “No person in the United States

shall, on the ground of race, color or national origin, be excluded from participation in, be

denied the benefits off, or be subjected to discrimination under any program or activity

receiving federal financial assistance.” If you feel you have been discriminated against in transit

services, please provide the following information in order to assist us in processing your

complaint and send it to:

Mary A. Keating

Director

DuPage County Department of Community Services

421 N. County Farm Road

Wheaton, IL 60187

Please print clearly or type:

Name: ________________________________________________________________________

Address: ______________________________________________________________________

City, State, Zip Code: ____________________________________________________________

Telephone/Cellular Number: ______________________________________________________

Name of person allegedly discriminated against: ______________________________________

Address of person alleged discriminated against: ______________________________________

City, State, Zip Code of person allegedly discriminated against:

_____________________________________________________________________________

Please check off why you believe discrimination occurred (check all that apply):

____Race

____National Origin

____Income

____Other (explain):________________________________________________________

What was the date of the alleged discrimination: _________________________________

Where did the alleged discrimination take place:__________________________________

Dupage County Title Vi Complaint Form - Dupage County Department Of Community Services