Civil Rights Complaint Form printable pdf download

Civil Rights Complaint Form

Title VI of the 1964 Civil Rights Act and related nondiscrimination statutes and regulations require

that no person in the United States shall, on the ground of race, color or national origin be excluded

from participation in, be denied the benefits of, or be subjected to discrimination under any

program or activity receiving federal financial assistance. Metro also prohibits discrimination based

on sex, age, disability, religion, medical condition, marital status, or sexual orientation.

In addition to utilizing the Civil Rights complaint process at City of Monrovia, a Complainant may

file a Title VI complaint concerning race, color or national origin discrimination with the Federal

Transit Administration (FTA), Office of Civil Rights, Region IX, 201 Mission Street, Suite 1650, San

Francisco, California 94105-1839. A Complainant may file an Americans with Disabilities Act (ADA)

complaint with the FTA, Director, FTA Office of Civil Rights, East Building – 5

Floor, TCR, 1200

New Jersey Ave., SE, Washington, DC 20590. Complainants may also contact the FTA ADA

Assistance Line, 1-888-446-4511 (Voice) or through the Federal Information Relay Service, 1-800-

877-8339 or by electronic mail at FTA.ADAAssistance@dot.gov. The FTA ADA Complaint form is

available at

The following information is necessary to assist us in processing your complaint. Should you

require assistance in completing this form, please let us know.

Complete and return this form to: City of Monrovia, City Manager’s Office, 415 S. Ivy Avenue,

Monrovia, CA 91016.

Complainant’s Name:

Address:

City:

State:

Zip Code:

Telephone Number (home):

(business):

Person discriminated against (if someone other than the Complainant):

Name:

Address:

City:

State:

Zip Code:

Which of the following best describes the reason you believe the discrimination took place?

Was it because of your:

a. Race

b. Color

c. National Origin

Civil Rights Complaint Form