Title VI Complaint Form

Title VI of the Civil Rights Act of 1964, 49 U.S.C. 47123, and the Age Discrimination Act of 1975 (Civil Rights Laws) prohibit discrimination on the basis of race, color, national origin, creed, sex, or age in any program or activity receiving federal financial assistance. The Department of Transportation also prohibits recipients receiving federal financial assistance from intimidating or retaliating against anyone, because he or she acts to secure rights protected by civil rights laws. If you believe your civil rights have been violated as a result of prohibited discrimination, intimidation, or retaliation you have the right to file a complaint.

Title VI Complaint Procedure

Title VI Complaint Form

Complainant’s Name

Address

City

State

Zip Code

Telephone

Who is responsible for the discriminatory action(s)

Name of Organization

Name of Individual (if known)

Location of Discrimination

What is the discrimination based on?

Race

Color

Sex

Creed

National Origin

Age

Date of the alleged discrimination

Describe the alleged discrimination. Explain what happened and whom you believe was responsible (additional sheets of paper may be attached to this form).

Attach Additional Documentation

One file only.
100 MB limit.
Allowed types: jpg, jpeg, png, txt, rtf, pdf, doc, docx, mov, mp3, mp4, ogg, wav.

List names and contact information of persons who may have knowledge of the alleged discrimination.

What remedy are you seeking?

Have you filed this complaint with any other Federal, State or local agency? If so, whom.

Please sign and date. The complaint will not be accepted if it has not been signed. You may attach any written materials or other supporting information that you think is relevant to your complaint. Please submit the complaint form to the agencies as soon as possible but no more than 180 days after the alleged occurrence.

Signature

Sign above

Date

The Title VI Complaint form may be submitted directly to the following agencies:

Title VI Coordinator: Robert W. Benstein, A.A.E., Vice President & COO
4100 Capital City Blvd
Lansing, MI 48906
517-886‐3713
rbeinstein@craa.com

*Within 15 days of receiving the completed form the Title VI Coordinator is required to submit the form to:

Federal Aviation Administration
Office of Civil Rights
via
FAA.CivilRightsConnect.com

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