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Online Complaint Form

Complaint under Title VI of the Civil Rights Act of 1964 and Related Statutes.

Your Information ("Complainant")


Name:

E-mail Address:

Address:

Telephone No.

Information about person you believe discriminated against you ("Respondent")

Name:

Address:

Telephone No.

Agency (if applicable):

I believe Respondent discriminated against me due to
(brief description):

Date of alleged Discrimination:

Please provide a description of alleged discrimination and include what
correction action(s) you would like taken on your behalf:

Have you filed a complaint alleging the same discrimination with another state or federal agency?

: Yes

: No

 

: Official Complaint (This box will serve as an official signature).

: Inquiry (No signature required) This office will seek informal resolution.


Indiana Department of Transportation
Title VI/ADA Administrator
100 N. Senate Ave. Room N750
Indianapolis, IN 46204
Phone: (317) 234-6142