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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant to the Federal Privacy Act (P1, 93-579) and the Information Practices Act of 1977 (Civil Cada 9octinns 1706 , At surd, notice in hereby given for the mquest or <br />pamcuul Infnrmalion by thio farm. The requested personal Information Is voluntary. Tho prodpal Once." of the voluntary, laban allon is to radlllate the processing of this farm. <br />The failure to provide all or any pad of the iequecfed Iofermailon may delay pmmassin9 of this from. No dledosure of personal Inlmmrallan will be made unless ponniesihle <br />under Aulde 6, section I7o0.24 of the IPA of WT. Each Indlaidoal has Iho right upon request and proper id,m6flwllon, to Inspect all tenement Inrormalian in my road <br />mainlmined on the lndiNdual hyanldenti n ndioulm. Directaa In shies on infmrmatlmn mfllnlenenca to our lPAOffice. <br />Dist Co RIC Post <br />13ASIS ON DISORINIINATION <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Diability ❑ Low -Income [] Non-English Speaker <br />Provide datc(s) and place of alleged discrimination <br />Describe the nature of [lie author, decision, or conditions of the alleged discrimination (Arach 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 infomlation about this allegation <br />action requested <br />NOTE; The use of the Title VI Discrimination Complaint tutor is not mandatory, you may proton your complaint In ally Serra Inar contains your <br />signature <br />75M-51 <br />