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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />persuanl lV Iho Federal Pdvaoy Ad (P.L, n357a) and the Iaf errucien Pfodlees Art of 1977 (Civil Code &e Vrns 1796, at SCh.), notice Is hereby given far the request of <br />personal icform.11ed Uy Illlstwm. The requesled peraag.1 Inf.mmliml Iswlunlery. Tho pdnaipal puryosa 4 the Va emery hfamma.eatt to f..illtale the pruc.ssfng of This form. <br />TNe reLo, to provide all at any pall of iha requested Informllel may delay pr.cea.rej of this fore. No disclosure of ppzrcaaat Iefonnallon WAll be mad. unlow permiss1th, <br />ander A6icle a, Scathe 179624 or the IPA of 1977. Each malignant las the right upon (egnast and proper Id.ra ffaalkn, to Insp.6 all personal infrmadon In any rocard <br />malnt.Ined amine lnflMdualb an ideebyhp wdimdr. OI clan In uirles on fnfnrma6on maint.nanra loy.Vr IPAClfice. <br />Dist CO Rte Post <br />)BASIS OR DISCRIMINATION <br />[] RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX D Diab(lity ❑ Low Incomo ❑ Non -&[glob Spoakor <br />Provide date(s) and place of alleged discrimination <br />Deneribe the nature of [be action, dccislon, or con dithers of the alleged discrimination (Attach Extra Page. If'Necessary) <br />Nemo ofludivi duals (NICneavn) responsible forthe ao4on, decision or condition of alleged discrimination <br />Provide supporting bdametton!mown to complain uatin support of bisMer allogalion <br />Identify possibte 19ifnesses whom (ba complainant believes can provide factual inforsrradon about this allegation <br />Stnte the action requested by complainant <br />750-45 <br />