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  • 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 another language or in alternate formats, please let us know.

  • Please submit, mail, or fax this form to:

    Nate Suttenfield, Executive Director

    Cole County Residential Services, Inc.

    1908 Boggs Creek Rd., Jefferson City, MO  65101

    ccrsi@ccrsi.org            Fax: 573-634-4352

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you prefer to be contacted by this e-mail address?
  • 2. Accessible Format of Form Needed?
  • 3. Are you filing this complaint on your own behalf?

  • 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.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you prefer to be contacted by this e-mail address?
  • 6. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third-party.
  • 7. I believe that the discrimination I experienced was based on (check all that apply):

  • 8. Date of Alleged Discrimination:
     - -
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  • 13. Have you filed a complaint with any other federal, state, or local agency; or with any federal or state court?
  • If "YES", check all that apply:

  • 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.)

  • Format: (000) 000-0000.
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  • Date of Signature:
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  • Date of Signature:
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