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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant W Ne Federal Pdvacy Ad (P.L 91579) was No INortreUon Pradims Art of 1977 (OW Colo Sessions 170. at sect), mtlm Is hereby given far the request d <br />persereal tnfamratian by Ws farm The requested personal irformnim is vduatary. The pdrMpal purpose N Ne vdua InbhmUan is Is faditate the Iasessdna of ells rams <br />The tdiure b pmbda a7 or my par of Na requeeled ecformftion may delay pmwsskq of Ws farm No ciisdosum mn ui <br />of personal INon9a9 be made unlessPermissible <br />ArUdo e, Section 1798.24 of No IPA of 1977. Each IrsWdual has Ne dgN upon request anti proper identification, to Inspect all persoml infamustion In any reostd <br />mstnudnNon Na Ndddual nvan WentiMtm pertldar. Cued em lmuidoaon Hfmvtiannidatmasa to Yom IPA 0111 <br />12 Orange 405 <br />Dist CO Rte <br />BASIS OF DISCRIMINATION <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGM ❑ SEX ❑ DISABILITY ❑ LOW-INCOME ❑ NON-ENGLISH SPEAKER <br />Provide date(s) and place of alleged discrimination <br />Describe the nature of the Action, decision. or conditions of the alleged discrimination(Attach Ex Page. If Necessary) <br />Name of Individuals (ifKnmvn) responsible for the action, decision or condition of alleged discrimination <br />Provide supporting information known to complainant in support ofhislherallegation <br />Identify possible witnesses whom the complainant believes can provide factual information about this allegation <br />Stale the action requested by complainant <br />75E-58 <br />