Title VI Complaint Form

Haga clic aquí para el formulario en español.

GTrans 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 the 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 GTrans Customer Service by calling (310) 965-8888.

Section I:
Name:
Address:
Telephone (Home):	Telephone (Work):
Email Address:

Section II:
Are you filing this complaint on your own behalf?	Yes*	No
*If you answered “Yes” to this question, go to Section III
If not, please supply the name and relationship for whom you are complaining:
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 I experienced was based on (check 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 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. If more space is needed, please use the back of this form.

Section IV:
Have you previously filed a Title VI complaint with this agency?	Yes	No

Section V:
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 Agency:
[]	State Court:		[]	Local Agency:
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 Number:

You may attach written materials or other information that you think is relevant to your complaint. Signature and date required below

Signature

Date

Please submit this form in person at the address below, or mail this form to:
Attn: Director of Transportation
City of Gardena
Department of Transportation
13999 S. Western Avenue
Gardena, CA 90249

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Title VI Complaint Form

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