Title VI Program Breadcrumb Home Title VI Program Title VI Plan Titile VI Plan Procedures Title VI Complaint Procedure file Training Video Title VI Awareness Training video Title VI Complaint Form Complainant’s Name Address City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Telephone Email 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 Date of the alleged discrimination: Date Date of the alleged discrimination: Time 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
