Title VI Form

* indicates a required field

Section I

Your First and Last Name*:   
Primary Phone*:   
Secondary Phone:   
Accessible Format Requirements? (Select all that apply):   
Large Print TDD Audio Tape Other

Section II

Are you Filing this complaint on your own behalf?*:
Yes No
If you answered YES to previous question, go to Section III. If not, complete section II:
Complainant Name:   
Relationship to Complainant:   
Please explain why you have filed for a third party:   
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party:
Yes No

Section III

I believe the discrimination experienced was based on (Select all that apply)*:
Race Color National Origin
Date of Alleged Discrimination (Month-Day-Year)*:   

Explain as clearly as possible what happened and why you believe discrimination occurred. Describe all persons who were involved. Include the name and contact information of any witnesses*:
(Attach any additional pages as needed.)   

Section IV

Have you previously filed a Title VI complaint with this agency?* Yes No

Section V

Name of agency complaint is against:
Contact person:
Telephone number:
Any other written information that you think is relevant to your complaint.

Section VI

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?*
Yes No
If yes, check all that apply: Federal Agency Federal Court State Court State Agency Local Agency
Please provide information about a contact person at the agency/court where the complaint was filed.

Sign and Submit Form

Mail form to:
          Cache Valley Transit District
          Attn: Curtis Roberts, Title VI Officer
          754 West 600 North
          Logan, Utah 84321

Signature:_______________________________________ Date:_______________________________