Discrimination Complaint and Title VI Form

River Cities Public Transit

Fill out and submit your Discrimination Complaint and Title VI Form

Name(Required)

First Middle Last

Date(Required)

Address(Required)

Street Address Apartment/Unit # City State ZIP Code

Phone(Required)

Email Address(Required)

Are you filing this complaint for someone else?(Required)

(if yes, whose civil rights do you believe were violated?

First Last

I believe that I have been (or someone else has been) discriminated against on the basis of:(Required)

Who or which RCPT agency do you believe discriminated against you?(Required)

River Cities Public Transit

Cheyenne River Sioux Transit

Haakon County Prairie Transit

Eastern Pennington County Transit

Hyde County Public Transit

Name:

Other

Who do you believe discriminated against you?

First Last

Date of incident:(Required)

Please describe how you were discriminated against. What happened and who was responsible?(Required)

Witnesses?(Required)

Yes

Witnesses? Please provide their contact info

Name

First Last

Address

Street Address City State ZIP Code

Home Phone:

Cell Phone:

Work Phone:

Name

First Last

Address

Street Address City State ZIP Code

Home Phone:

Cell Phone:

Work Phone:

Name

First Last

Address

Street Address City State ZIP Code

Home Phone:

Cell Phone:

Work Phone:

Did you file this complaint with another federal, state, or local agency; or with a federal or state court?(Required)

Yes

If you answered yes, please check each agency the complaint was filed with:

Federal Agency

Federal Court

State Court

State Agency

Local Agency

Other

Provide contact person information for the other agency you also filed complaint with:(Required)

First Last

Address(Required)

Street Address City