Title VI Complaint Form and Procedures
Marion County Senior Citizens, Inc. 
TITLE VI COMPLAINT FORM

"No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance."

If you feel that you have been discriminated against in the provision of transportation services, please provide the following information to assist us in processing your complaint.  Should you require any assistance in completing this form or need information in alternate formats, please let us know.

Please mail or return this form to:  
Director; Marion County Senior Citizens, Inc.; 105 Maplewood Drive; Fairmont, WV 26554
debbie@marionseniors.org   OR   Fax: 304-366-3186

Download form and instructions

1. Complainant’s Name: ______________________________________________________________________________

a.  Address:________________________________________________________________________________________

b. City: _____________________________State: ____________Zip Code: ______________

c.  Telephone (Home ☐ or Cell ☐)  Please include area code     Telephone Number (Work)

( ____) ____________________________________              (______)  ____________________________________________

d.  E-Mail Address: ______________________________________________
Do you prefer to be contacted via this e-mail address?  ☐Yes       ☐No

2. Accessible Format of Form Needed?
☐ Large Print    ☐ Audio Tape    ☐ TDD
☐ Other (please specify): ____________________________

3.  Are you filing this complaint on your own behalf?    
☐ Yes     If YES, please go to Question 7
☐  No     If NO, please go to question 4

4.  If you answered NO to question 3 above, please provide your name and address.

a.  Name of Person Filing Complaint: ___________________________________________________________________________

b. Address: ______________________________________________________________________________________________

c. City:  ________________________________________State:  _______________ Zip Code:  ________________________

d. Telephone (Home ☐ or Cell ☐)  Please include area code   Telephone Number (Work)

( ____) ____________________________________             (______)  ____________________________________________

e.  E-Mail Address:
Do you prefer to be contacted via this e-mail address?  ☐Yes       ☐No

5. What is your relationship to the person for whom you are filing the complaint?

__________________________________________________________________________________________________

6. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
☐Yes, I have permission.   ☐No, I do not have permission.

7.  I believe that the discrimination I experienced was based on (check all that apply)
  Race       Color      ☐ National Origin (Classes protected by Title VI)    Other (please specify):_________________________

8. Date of Alleged Discrimination (Month, Day, Year): ______________________________________________

9. Where did the Alleged Discrimination take place?_______________________________________________

10. Explain as clearly as possible what happened and why you believe that you were discriminated against.  
Describe all of the persons that were involved.  Include the name and contact information of the person(s) who discriminated against you (if known). Use the back of this form or separate pages if additional space is required.

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

11. Please list any and all witnesses’ names and phone numbers/contact information.
Use the back of this form or separate pages if additional space is required.


12. What type of corrective action would you like to see taken?


13. Have you filed a complaint with any other Federal, State, or local agency, or with any Federal or State court?   
Yes    If yes, check all that apply              No

a.☐Federal Agency (List agency’s name)
b.☐ Federal Court (Please provide location)
c.☐ State Court
d.☐ State Agency (Specify Agency)
e.☐ County Court (Specify Court and County)
f. ☐ Local Agency (Specify Agency)

14. Please provide information about a contact person at the agency/court where the complaint was filed.

Name:  _______________________________    Title:  _______________________________

Agency: _______________________________  Telephone (_____)__________________________

Address:  _______________________________

City: ___________________________________    State: __________________     Zip Code:  _______________

You may attach any written materials or other information that you think is relevant to your complaint.
Signature and date is required:

 
______________________________                      _______________________                                                     
Signature                                                                        Date

If you completed Questions 4, 5 and 6, your signature and date is required


______________________________                      _______________________                                                      
Signature                                                                        Date

 

Title VI Complaint Form and Procedures
Marion County Senior Citizens, Inc.
 Title VI Procedures

Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”

 Any person who believes that he/she has been aggrieved by an unlawful discriminatory practice on the basis of race, color or national origin by Marion County Senior Citizens, Inc. may file a complaint by completing and submitting to Marion County Senior Citizens, Inc. the Title VI Complaint form.

How do you file a complaint?

You may download the Marion County Senior Citizens, Inc. Title VI Complaint Form at www.marionseniors.org, or request a copy by writing or phoning Marion County Senior Citizens, Inc. 105 Maplewood Drive, Fairmont, WV 26554 or 304-366-8779.

 You may file a signed, dated and written complaint no more than 180 days from the date of the alleged incident. The complaint should include:

☐  Your name, address and telephone number. (See Question 1 of the Complaint Form)
☐   How, why, and when you believe you were discriminated against. Include as much specific, detailed information as possible about the alleged acts of discrimination, and any other relevant information. (See Questions 7, 8, 9, and 10 of the Complaint Form)
☐    The names of any persons, if known, whom the director could contact for clarity of your allegations. (See Question 11 of the Complaint Form)

Please submit your complaint form to address listed below:
Director; Marion County Senior Citizens, Inc; 105 Maplewood Drive;  Fairmont, WV 26554

 How will your complaint be handled?
Marion County Senior Citizens, Inc. investigates complaints received no more than 180 days after the alleged incident. Marion County Senior Citizens, Inc. will process complaints that are complete. Once a completed complaint is received, Marion County Senior Citizens, Inc. will review it to determine if Marion County Senior Citizens, Inc. has jurisdiction. The complainant will receive an acknowledgement letter informing her/him whether the complaint will be investigated by Marion County Senior Citizens, Inc.

Title VI Complaint Form and Procedures

Marion County Senior Citizens, Inc. will generally complete an investigation within 90 days from receipt of a completed complaint form. If more information is needed to resolve the case, Marion County Senior Citizens, Inc. may contact the complainant. Unless a longer period is specified by Marion County Senior Citizens, Inc., the complainant will have ten (10) days from the date of the letter to send requested information to the Marion County Senior Citizens, Inc. investigator assigned to the case.

If Marion County Senior Citizens, Inc. investigator is not contacted by the complainant or does not receive the additional information within the required timeline, Marion County Senior Citizens, Inc. may administratively close the case. A case may be administratively closed also if the complainant no longer wishes to pursue their case.

After an investigation is complete, Marion County Senior Citizens, Inc. will issue a letter to the complainant summarizing the results of the investigation, stating the findings and advising of any corrective action to be taken as a result of the investigation. If a complainant disagrees with Marion County Senior Citizens, Inc. determination, he/she may request reconsideration by submitting a request in writing to Marion County Senior Citizens, Inc. director within seven (7) days after the date of Marion County Senior Citizens, Inc. letter, stating with specificity the basis for the reconsideration. The director will notify the complainant of his decision either to accept or reject the request for reconsideration within 10 days. In cases where reconsideration is granted, the director will issue a determination letter to the complainant upon completion of the reconsideration review.

A person may also file a complaint directly with the Federal Transit Administration, at FTA Office of Civil Rights, 1200 New Jersey Avenue SE, Washington, DC 20590.
If information is needed in another language, then contact Marion County Senior Citizens, Inc. at 304-366-8779.