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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursutnl to the Federal Nivaay Act (P.L. 03-578) and the Information Patentees Act cf 1977 (Civil Cade Sections Me , Olsen.), notim is hereby given For the request of <br />paromollnfamrullonbylhis form. The ragnested parsunal lnformadon is voluNory. The pdndpai purposrs of the voNnlaryinfnrmallon is to facllllate the proweeing of lhls form. <br />The failure to prodde all ar any Of of tha requested inlormanlon may delay processing of this form. No diaslomea of persons[ infirm alion will be made unless parmisalbls <br />andelAlan. 6, Section 1708.24 of the IPA of 1077. Each Individual has the right upon request and proper Ideniliicalion, to Inspect all personal Informallon in any ream <br />maintained on the lotividuai Lty on arnalrying particular. Direct any Inquiries an irenrmallmt armistaoseenl IPA 010 <br />Dist Co Rte Post <br />BASIS <br />❑ RACE ❑ COLOR [] NATIONAL ORIGIN [] SEX ❑ Dial ❑ Low -Income ❑ Nott arglish Speaker <br />Provide date(s) and place of alleged discrimination <br />Describe the Names of the action, decision, or conditions of the alleged discrimination (Attach Extra Page. If Necessary) <br />Name of individuals (if Known) responsible for the railcar decision or condition of alleged discrimination <br />Provide supporting information known to complainant in support ofhis/her allegation, <br />Identify possible witnesses whom Ale complainant believes can provide factual information about this allegation <br />State the action requested by complainant <br />75H-39 <br />