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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant to Ne FedWaI Pr nary pd (P.L 93518) and the Worm ton Precgms Ad .11977 (Ciwl Code Sccllons 1798. e1 see.), ngum is hereby given rcr No request of <br />Persovd In orrnadon by Nis (.int The requesled personal INomallon Is voluntary. Thu piincpal pury.sa of the voluntary Infmmag.n is to facilitate the pmmsdrg of We form. <br />The failure be provide a9 or any part of No requesletl adomva.n may delay processing of we fmrrt Na dsdowro of personal Nformaa.n will be made udess Pemdsslble <br />under Md. 6, 9ed(em 1.79929 of No IPA of 19Th Each inoititlual has Na dght upon request aM poser itlen'you" to inspect all persmal Inf.irna9o. in etry record <br />h I le' ed .0 , dl'd Iffy bl Ifv' nparend .'vett nonquI" information ' 1 ce f. your lPA Office. <br />12. Orange 405 <br />Dist Co Rte <br />BASIS OF DISCRIMINATION <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ DISABILITY []LOW-INCOME ❑ NON-ENGLISH SPEAKER <br />Provide datc(s) and place ofalleged discrimination <br />Describe the nature of the action, decision, or conditions of the alleged discrimination (Attach Extra Page. If Necessary) <br />Name of individuals (if Known) responsible for the action, decision orcondition of alleged discrimination <br />Provide supporting information known to complainant in support of his/her allegation <br />Identify possible tvitnesse i whom the complainant believes can provide factual information about this allegation <br />State the action requested by complainant <br />75D-81 <br />