PRINTABLE TITLE VI DISCRIMINATION COMPLAINT FORM 

Please print out this form, fill it out and mail it to: GNHTD, or ConnDOT, or the Federal Transit Administration.

Name:  ______________________________________________________________

Street Address:  _______________________________________________________

Apt.#:  _______________________________________________________________

City or Town/State/Zip Code:  ___________________________________________

Phone:  ______________________________________________________________

Discrimination because of: __Race __Color __National Origin __Sex __Age __Disability __Other

Please provide the date(s) and location of the alleged discrimination, the name(s) of the
individual(s) who allegedly discriminated against you including their titles (if known).
 

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Please provide the names, addresses and telephone numbers of any witnesses.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Explain as briefly and as clearly as possible what happened, how you feel that you were discriminated against and who was involved. Please include how other persons were treated differently from you. 

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________



_____________________________________________________________
Signature/Date

You may use additional sheets of paper if necessary. Also include any written
materials pertaining to your complaint.