Form 0112 - Title Iv-Compliant Form
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TITLE VI – COMPLAINT FORM
Michigan Department
Page 1 of 2
Of Transportation
0112 (01/17)
Title VI of the Civil Rights Act of 1964 states that, “No person in the United States shall on the basis of race, color, or
national origin, be excluded from participation in, be denied the benefit of, or otherwise be
to discrimination
in any program, service, or activity receiving federal financial assistance.”
This form may be used to file a complaint with the Michigan Department of Transportation (MDOT) for alleged
violations of Title VI of the Civil Rights Act of 1964. If you need assistance completing this form,
please
contact us by phone at (517) 373-0980 or via FAX (517) 335-8841 or TDD/TTY through the Michigan Relay
Center at (800) 649-3777.
Only the complainant or the complainant’s designated representative should complete this form.
NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME TELEPHONE
WORK TELEPHONE
FAX
Individual(s) discriminated against, if different from above (use additional page(s) if necessary):
NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME TELEPHONE NO.
WORK TELEPHONE NO.
FAX NO.
PLEASE EXPLAIN YOUR RELATIONSHIP TO THE INDIVIDUAL(S) INDICATED ABOVE
Name of Agency and department or program that discriminated:
AGENCY AND DEPARTMENT NAME
NAME OF INDIVIDUAL (If known)
STREET ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NO.
FAX NO.
Date(s) of alleged discrimination:
DATE DISCRIMINATION BEGAN
LAST OR MOST RECENT DATE OF DISCRIMINATION
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