CCRSI Title VI Complaint Form

COLE COUNTY RESIDENTIAL SERVICES, INC.
TITLE VI/ADA COMPLAINT FORM

"No person in the United States shall, on the basis of race, color, national origin or disability be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance."

If you feel that you have been discriminated against in the provision of transportation services, please provide the following information to assist us in processing your complaint. Should you require any assistance in completing this form or need information in alternate formats, please let us know.
Please submit, mail, or fax this form to:

Jim Casey, Executive Director

Cole County Residential Services, Inc.

1908 Boggs Creek Rd., Jefferson City, MO 65101

ccrsi@ccrsi.org Fax: 573-634-4352
1. Complainant's Name:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home:
Cell:
Work:
E-mail Address:
Do you prefer to be contacted by this e-mail address?

YesNo
2. Accessible Format of Form Needed?

YesNo
3. Are you filing this complaint on your own behalf?

YesNo
If Question #3 is "YES", go to Question #7.
4. If you answered "NO" to Question 3 above, please provide your name, and contact information below.
Name of Person Filing Complaint:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address:
Home:
Cell:
Work:
5. What is your relationship to the person for whom you are filing the complaint?
6. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third-party.

YesNo

7. I believe that the discrimination I experienced was based on (check all that apply):

Race (Class Protected by Title VI)Color (Class Protected by Title VI)National Origin (Class Protected by Title VI)Disability (Class Protected by ADA)Other
8. Date of Alleged Discrimination:

MonthDayYear
9. Where did the Alleged Discrimination take place?
10. Explain as clearly as possible what happened and why you believe that you were discriminated against. Describe all of the persons that were involved. Include the name and contact information of the person(s) who discriminated against you (if known). If necessary upload additional pages below.
Additional Information to Upload for #10:
11. Please list any and all witnesses' names and phone numbers/contact information. If necessary upload additional pages below.
Additional Information to Upload for #11:
12. What type of corrective action would you like to see taken?

13. Have you filed a complaint with any other federal, state, or local agency; or with any federal or state court?

YesNo
If "YES", check all that apply:

Federal Agency (specify agency)State Agency (specify agency)Local Agency (specify agency)Federal Court (specify location)State CourtCounty Court (specify Court and County)
Specify the Agency and/or Court information that is referenced above:
14: If "YES" to Question 13 above, please provide information about a contact person at the agency/court where the complaint was filed. (Attach additional information below if necessary.)
Full Name

First NameLast Name
Title:
Agency:
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Upload Additional Contact Information:
You may attach any written materials or other information that you think is relevant to your complaint.

Complainant's Signature:

Clear
Date of Signature:

MonthDayYear
If you completed Questions 4, 5, and 6, your signature is required:

Clear
Date of Signature:

MonthDayYear
Should be Empty: