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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Putauaut to Ins Fedeml Pdvacy Act P.L. 93-579) and the Information Purchase Act of 1977 (Civil Cade Socllons 1799 , at aogJ, nonce Is hereby given far the request of <br />personal inrormalfon by this form. The requested pamonal harmanon Is m u ttery. The pdooli al purpose of the voluntary Information is to portals the processing of this fans. <br />The (allure In provide all or any part of the requested information may delay processing of this forth. No dlsolosure of p,.are Infomation will be made unless permissible <br />under Adicls 6, Section 1790.24 or the IPA of 1977. Each Individual has the right upon request and proper Identi talion, be Inspect all personal Warranties In any record <br />niaintainedenth indrvdualby,anidenti in articular. Cheer any in airies on lnlormatten maintenance, to your IPA On <br />Dist <br />Nam: of Complainant <br />Co Rte <br />BASIS Or DISCRIMINATION <br />Post <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Liability ❑ Lmv-meront ❑ Noll -English Speaker <br />Provide date(s) and place of alleged dcauhninatinn <br />Describe the nature ofthe action, decision, or conditions of the alleged discrimination (Attach Extra Page. If Necessary) <br />Name of individuals (if Knows) responsible for the action, decision or condition of alleged discrimination <br />Provide supporting information known to co nplainont in support of his/her allegation <br />Identify possible witnesses whom the complainant believes can provide factual information about this allegation <br />Slate the action requested by complainant <br />75N-45 <br />