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2. The Federal Transit Administration (FTA) requires Transit Agencies to operate Transit Programs per Title VI without regard to Race, Color, National Origin, Age, or Family or Religious Status. The Americans with Disabilities Act (ADA) of 1990, As Amended must also be followed. Please complete this form if you feel you have been discriminated against for any reason.
4. Section 1
6. Name*
7. Address*
9. Telephone (Mobile/Home)*
10. Telephone (Work)
12. Accessible Format Requirements?

    1. Large Print
    2. TDD
    3. Audio Tape
    4. Other
13. If other, please fill in below
15. Sumter County Transit Title VI Plan
    View Here
19. Section 2
21. Are you filing this complaint on your own?
    -- Select One --YesNo
22. If you answered "Yes" to this question, go to Section 3.
24. If not, please supply the name and relationship of the person for whom you are complaining:
25. Please explain why you have filed for a third party:
26. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
    -- Select One --YesNo
30. Section 3
32. I believe the discrimination I experienced was based on Title VI per FTA Circular 4702.1B (check all that apply below):*

    1. Race
    2. Color
    3. National Origin
    4. Age
    5. Family or Religious Status
    6. Other
    7. N/A
33. I believe the discrimination I experienced was based on Americans with Disabilities Act (ADA) per FTA Circular 4710.1:*

    1. Disability
    2. N/A
35. Other (Specify here):
37. Date of alleged discrimination (Month, Day, Year)*
38. Location*
40. Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.*
44. Section 4
46. Have you previously filed a Title VI or ADA complaint with this agency?
    -- Select One --YesNo
47. Please provide a date and case number if applicable
51. Section 5
53. Have you filed this complaint with any other Federal, State or local agency, or with any Federal or State Court?
    -- Select One --YesNo
54. If yes, check all that apply:

    1. Federal Agency
    2. Federal Court
    3. State Agency
    4. State Court
    5. Local Agency
55. If yes, please provide a case/reference number:
57. Please provide information about a contact person at the agency/court where the complaint was filed (Include name, title, agency, and address).
61. Section 6
63. Name of agency complaint is against:*
64. Contact person:
65. Title:
66. Telephone number:
68. You may attach any written materials or other information that you think is relevant to your complaint.
70. By checking the box below and submitting this form, I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.*

    1. I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.
72. If information is needed in another language, please contact (352) 689‐4400.
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74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

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