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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />--- <br />parspanl toof the patlaml Privacy Acl. r" 9&519) and the Intonnallan Practices Ad or 1917 (Civil Code fther dr, 1]90,fo ratio halloo L hereby the <br />given rorthe request of <br />Tpars hefaielretonelionbylllhl. <br />or farm, Th. the voloplavy- The ofthis purposeofthe voluntaryinformallon isto faallilalo Rhaopecasing or ithis farm. <br />Tha (hilum a provide all or any potl of the mfessled IEach Inds may delay a mile upon <br />coo, form. N r disclosure of personal informallon will al made tion I p any <br />recole <br />rd <br />under Antde 6, a I'divi 7190.24 0l the IPA of 1911. Each Indivl1. has the right upon request and proper IPA FI ration, to Inspect all personal information In any recortl <br />malnlalued on the Individual hY an Idonlilying particular. Oirecl an Y lnqulnes on Informallon m In[enan I our IPA Ofp <br />Name of Complainant <br />Dist Co <br />BASIS OF DISCRIMINATION <br />Rte Post <br />❑ RACE ❑ COLOR Q NATIONAL ORIGIN ❑ SEX ❑ Diability ❑ Low4ro me ❑ Non-English Speaker <br />Provide date(s) and place of alleged discrimination <br />Describe the nature oFthe action, decision, or conditions of the alleged discrimination (Attach ExbA Page. IF Necessary) <br />Name of individuals (if Known) responsible For the action, decision or condition of alleged discrimination <br />Provide supporting Information known to complainant it, support of his/her allegation <br />Identify possible witnesses tvhatn the complainant believes can provide factual information about this allegation <br />State the action requested by complainant <br />751-39 <br />