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ATTACHMENT 6 <br />TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant to the Federal Privacy Act (P.I. 93.579) and the Information Practices Act of 1977 (CMI Code Sections 1798, at seq.), nonce 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 crime form. <br />The failure to provide all or any pen of the requested information may delay processing of this forte. No disclosure of personal Information will be made unless permissible <br />under Article 6, Section 1788.24 of the IPA of 1977, Each Individual has the fight upon request and proper identireation, to Inspect all personal information In any record <br />maintained on the Indlddual by an identifying padlcular. Direct any Inquiries on Information maintenance to your IPA Of oo. <br />Dist <br />Co Rte Post <br />BASIS OR DISCRIMINATION <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 whom the complainant believes can provide factual information about this allegation <br />by <br />75G-26 <br />