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ATTACHMENT 6 <br />TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant to fha Fatleml Privacy Act (P.L, 93 579) antl the Infennailon Pr.cacss Acl of 197] (Cidl Coda Sections 1798 at seq.J, notice Is hereby given for the request of <br />personal information by this form. Tha requested persenal lntonnallon is voluntary. The principal purpose of the voluntary lnformallon is to fadlliate Ne processing of this forth. <br />Thera <br />to protide all or any part of the requaslad Information may delay processing o! This Conn. No tllsclosura of personal lnformallon will be made unless pennlsslble <br />untler Adiela e, Section 179824 of the IPA of 19]]. Each Indiddual has the tlgm upon request antl proper itlenbOrafion, fo inspad all personal information In any record <br />mainfalnetl on lh.1rdlddual b an identif in articular, Olrect an in uiries on lnfaonesen maintenance to our lPA Otfce. <br />Dist Co <br />BASIS OF DISCRIMINATION <br />Rte Post <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Diability ❑ Low -Income ❑ Nan-Englisb Speaker <br />Provide dete(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 (ifKnosm) responsible for the action, decision or condition of alleged discrimination <br />Provide suppoRing information known to complainant in support of his/her allegation <br />Identify possible witnesses whom the complainant believes can provide factual information about this allegation <br />State the action requested by complainant <br />75F-49 <br />