Title VI Complaint Form

GAAMHA, Inc.
Complaint Form

Title VI of the 1964 Civil Rights Act requires 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.” If you feel you have been discriminated against in transit services, please provide the following information in order to assist us in processing your complaint.

Section I
Name:_________________________________________
Address:_______________________________________
Telephone Numbers:
(Home)_______________(Work)___________________
Email Address:___________________________
Do you need an Accessible Format?
Large Print _______ Audio tape _____
TDD ___________ Other________________________________________

Please indicate why you believe the alleged discrimination occurred:
______ Race or Color
______ Gender
______ National Origin
______ Income
______ Disability
______ Other

Section II
Are you filing this complaint on your own behalf?
Yes ____ No ____
[If you answered “yes” to this question, go to Section III.]
If not, please supply the name and relationship of the person for whom you are complaining: _________________________________________________
Please explain why you have filed for a third party. _____________________________
______________________________________________________________________
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
Yes ____ No ____

Section III
Have you previously filed a Title VI complaint with GAAMHA, Inc? Yes____ No___
Have you filed this complaint with any of the following agencies?
MassDOT _____ U.S. Department of Transportation ____
Department of Justice_____ Equal Employment Opportunity Commission _____
Other _____________________________________________
Have you filed a lawsuit regarding this complaint? Yes_____ No____
If yes, please provide a copy of the complaint form.
[Note: However, if your case has gone to court on the same issues, we defer to the
decision of the court.]
Section IV
Please describe your complaint. You should include specific details such as names, dates, times, route numbers, witnesses, and any other information that would assist us in our investigation of your allegations. Please also provide any other documentation that is relevant to this complaint.
Section V
May we release your identity to the transit department?
Yes ____ No ____
Please sign here: _____________________________________________
Date: ______________
Note – We cannot accept your complaint without a signature.
________________________________________
Please send your completed form to: GAAMHA, Inc., Attention: Tracy Hutchinson, 208 Coleman Street, Gardner, MA 01440 or gabusiness@gaamha.org