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ATTACHMENT 6 <br />TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant N rho Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798 , at seq.), notes is hereby given for the request of <br />personal Information by this form. The requested personal information is voluntary. The principal purpose of the voluntary Information is to facilitate the processing of this farm. <br />The torture to provide all or any ped of the requested Information in by delay processing of this fore. No disclosure of personal Information will be made unless permissible <br />under Audio 6, Section 179824 of the IPA of 1977. Each Individual has the right upon request and proper identlticalion, to Irspecl all personal Information In any retard <br />maintained N individual by identifying particular. Direct y l q ' f 1' Ile ante to your IPA CKca <br />Dist Co Rte <br />BASIS OF DISCRIMINATION <br />Post <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Diability ❑ 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 Extra Page. If Necessary) <br />Name of individuals (if Known) responsible for the action, decision or condition of alleged discrimination <br />Provide supporting information known to complainant in support of his/her allegation <br />Identify possible witnesses whonr the complainant believes can provide factual information about this allegation <br />Stale the action requested by complainant <br />75E-27 <br />