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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursamt to Iho Fodaml Privacy Act (P.L. 93L79) and the Incerallor, Practices Act of IB77 (CNII Code Seasons 179a, at Beg.), notice Is hereby given for the request of <br />monemml informatlm by this form. The requested personal let ...do. is voluntary. The principal traumas ofthe voluntary Information is to facililata Ilea aemse ing of this learn. <br />The failure to provide all or any part of the aquesied Infmmatien may delay processing of Ihia fomt. No disclosure of remnant infomation Whir be made unless parmis,lble <br />under Article B, Basilan 1709.24 of the IPA of 1W7. Each individual hoe ileo of,, <br />upan roquasl end paper Identification, to Inspect ell Pomona] infmmatlon In any reco d <br />maintained on the IndfAc e.l by as Identifying particula, eireci any Inquides on Hfomatlon malnlenanes to your IPA Office. <br />Dist Co <br />BASIS OF DISCRIMINATION <br />Rte Post <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Diabihty ❑ Low -Income ❑ Non-English Speaker <br />Provide data(s) and pita.. of alleged discrimination <br />Describe thenature 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 informatieu known to complainant in support ofbis/her allegation <br />Identify possible witnesses whom the complainant believes can provide factual information about this allegation <br />State the action requested by complement <br />75J-48 <br />