Title VI Complaint Form

Jackson Area Transportation Authority (JATA) investigates Title VI complaints received no more than 180 days after the alleged incident.

JATA has 15 calendar days to investigate the complaint. If more information is needed, JATA may contact the complainant.

After the investigator reviews the complaint, he/she will issue one of two letters to the complainant: a closure letter or a Letter of Finding (LOF).

A closure letter summarizes the allegations and states that there was not a Title VI violation and that the case will be closed.
A LOF summarizes the allegations and the interviews regarding the alleged incident, and explains wheter any disciplinary action, additional training of the staff member, or other action will occur.

If the complainant wishes to appeal the decision, he/she has 15 calendar days after the date of the closure letter or the LOF to do so.

A person may also file a complaint directly with the Federal Transit Administration (FTA), at the FTA Office of Civil Rights, 1200 New Jersey Avenue SE, Washington, D.C. 20590.

You are not required to use this format to submit a Title VI complaint; a letter with the same information is sufficient.

If you need this complaint form/information provided in an accessible format, please indicate below:

Large Print
Audio File
TDD
Another language

Hidden

If another language, please specify which language

Section 1

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Section 2

Are you filling this form out on your own behalf?

Yes
No

If yes, go to Section III

Please provide the name and relationship of the person for whom you are complaining:

Explain why you are filing for this person:

Have you obtained permission from this person?

Yes
No

Section 3

I believe the discrimination I experienced was based on (check all that apply)

Race
Color
National Origin

Date of Alleged Discrimination

Explain in detail what happened and why you believe you were discriminnated 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.

Section 4

Have you previously filed a Title VI complaint with the agency?

Yes
No

Section 5

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

Yes
No

If yes, check all that apply:

Federal Agency
Federal Court
State Agency
State Court
Local Agency

Please provide the contact information for a person at the agency where the complaint was filed.

Please provide the persons Name, Business Title, Agency, and Telephone Number

E-Signature

Please type your name to let stand for E-Signature

Date

JATA operates without regard to race, color, or national origin. If you need assistance completing this form, contact JATA at 517-780-3780 or email chad.cumberworth@jacksontransit.com.

Please submit this form in person at the address below, or mail to:

Jackson Area Transportation Authority
Attn: Title VI Coordinator
2350 East High Street
Jackson, MI 49203

CAPTCHA