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FRS Transportation -- Title VI Complaint Form

SECTION I: CONTACT INFORMATION


Your Name:

Street Address:

City:

State:

Zip Code:

Phone (Home/Cell):

Phone (work):

Email:


Accessible Format Requirements

Large Print TDD Audio Other

SECTION II:


Yes No  (If you answered "yes" go to Section III)

If not, please supply the name and relationship of the person for whom you are complaining:


Please explain why you have filed for a third party:



Yes No


SECTION III:



Date of alleged discrimination (month, day, year)


Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.
SECTION IV:

Yes No

SECTION V:

Yes No


Federal Agency

Federal Court

State Agency

State Court

Local Agency

Local Court


Please provide information about a contact person at the agency/court where the complaint was filed:
Name:

Title:

Agency:

Address:

Telephone:

SECTION VI:

Name of agency complaint is against:


Contact Person:

Title:

Telephone:


You may attach any written or other information that you think is relevant to your complaint.

Signature and date required below:

Signature:  
Date:         


You can submit this form online by pressing the SUBMIT button below or printing this page (Google Chrome will give proper printing results) and submitting it in person at the following address:

FRS Group, Inc.
Title VI Client Rights Officer
104 Erin Court
Hillsboro, OH   45133

or print and mail this form to:

FRS Group, Inc.
Title VI Client Rights Officer
P.O. Box 823
Hillsboro, OH   45133

NOTE: If information is needed in another language, then contact (937)393-4562 or (937)393-0585.




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