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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant to the Federal Privacy Act (P,L. 99-579) and the Informalien Pmdlcse Act of 1977 (Civil Code Seddon, 1798 , at seq.), noilm Is hereby given for the request of <br />cro <br />ponsl ln(orecatien by [his form. The requested personal lnformallonlavoluntary. The principal purpose of the volunfary Information is to hardiest the processing of this form. <br />The failure to provide all or any pad of the requested ]nfarmalien may delay processing of this form. No disebsure of personal Intreardbe v411 be used. unleas pmmlealble <br />under Anne fi, Scotian 1798,24 of the NA of 1977. Each individual has the right upon request and proper Identification, to Inspect all personal Information In any record <br />Inalnlainad on the Individual by an identifying patlicular. olrect enY Inauidas on InOnnalba neird.nence to Your IPA once. <br />Name <br />Dist CO <br />BASIS OR DISCRIMINATION <br />Rte Post <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Diability ❑ Low-bacome ❑ Non-English Speaker <br />Provide dates) and place of alleged discrimination <br />Describe the nature of the action, decision, or conditions of the alleged discrlmination (Attach Extra page. If Necessary) <br />Name of individuals (il'Known) responsible for the action, decision or condition of alleged discrimination <br />Provide supporting information known to complainant in support ofhia/ her allegation <br />Identify possible witnesses whom the complainant believes can provide gusto linformation about this allegation <br />State the action requested by complainant <br />NOTE,: The usn of thc't'itle Vl Discrlminotleu Complaint form is not mandatory. You may submit your cmnpialnt in any form that contains your <br />signature <br />75L-54 <br />