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TITLE VI DISCRIMINATION COMPLAINT <br />12 orange 405 <br />Dist Co Rte <br />BASIS OF.DISCRIMWATION <br />❑RACE' ❑COLOR ❑NATIONALOWIN []SEX []DISABILITY []LOW-INCOME ❑NON-LNNOLISHSPEAKER <br />Provide date(s) and place of alleged diseriminadon <br />Describe the nature of the action, decision, or conditions of the alleged discrimination (Attach Extra Page. IfNecessuy) <br />Name of individiiats (if Known) responsible forthe actidn, decision or candition of alleged discrimination <br />Provide supporting information known to complainant in support of his/her allegation <br />Identify possible witnesses Whom the complainant believes can provide formal information about this allegation <br />State the action requested by complainant <br />7501-146 <br />