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Title VI Reporting Form

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Minnesota Valley Transit Authority Title VI Report

PART I – INDIVIDUAL INFORMATION

Name(Required)
Address(Required)

PART II – ALLEGED DISCRIMINATING OFFICIAL(S) INFORMATION

Name(Required)
Address(Required)

PART III – CAUSE OF DISCRIMINATION BASED ON

Check appropriate box [es]
Cause of Discrimination(Required)

PART IV – THE PARTICULARS ARE

(Include names, dates, places, and incidents involved in the complaint.)

PART VI –COMPLAINT FILED WITH OTHER AGENCIES

Have you filed this compliant with any other federal, state, or local agency; or with any federal or state court?
Complaint Filed with Other Agencies(Required)
If yes, check each box that applies:(Required)

If you filed this complaint elsewhere as well, please provide information about a contact person at the agency/court where the complaint was filed.

Name(Required)
Address(Required)

PART VII – VERIFICATION

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.