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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant to the Federal Privacy Act P.L. 83.679) and the information Practices Act of 1977 (Mil Code Sections 1708, st seq), cause Is hereby given far the request of <br />personal Information by this farm. The requested personal information Is voluntary. The principal purpose of the voluntary Information is to facilitate the processing of this form. <br />The failure is provide all or any pact of the requested lefomralinn may delay promising of this fora,. No elect osum of it roanal Information will be mod. unless permissible <br />..do, Article 6, Soclion 1798.24 of the IPA of 1977. Each inclMduml has the right upon @memo Ono proper Identification, to impact all prrs... I iafmmallon In any record <br />mrrololned on the indIvictel by an identifying parucular. Direct mor ingress an information maintenance t. your IPA Offlce <br />Mailing Address <br />Dist CO <br />BASIS OF UISCIUMiNATION <br />Rte <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Oiability, ❑ Low-income ❑ Non-English Speaker <br />Provide dotes) and place of alleged discrimination <br />Dcscribe the nature of the action, decision, or conditions arthe alleged discrimination (Attach Extra Page. If Necessary) <br />Noma of individuals (if Known) responsible for the return, decision at condition afallaged discrimination <br />Provide supporting information known to complainant in support of his/her allegation <br />Identify possible wlincascs whonr the complainant believes can provide factual information about this allegation <br />State the action requested by complainant <br />75Q-46 <br />