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TITLE VI DISCRIMINATION COMPLAINT <br />PURSONALINFORMATION NOTIO[ <br />Pti snahl to the Federal Privaoy Act (RL. 03.879) and the Infmmallen Practices Ad of 1977 (Cindf Code Sections 1990 , of see.), notice Is hereby acre for the redirect of <br />personal infmmallon by thin form. The requested personal Information is voluntary, The principal purpose ofthe voluntary, Information is to mandate the processing ofthle Point. <br />The failure to provide all or any part or the requested Information may delay processing of this form. No disclosure of personal Influential will be made unless parrelasible <br />under Article A, Caoellnn 1798.24 of the IPA of 1!177. Each ImlMdual has the east upon request and proper identifleslion, to Inspect all personal information In any record <br />malreciredenthe indivldutdil au idenlilNnq padic 1 DI t y' q Itl f tl el tie aeroto your IPA Office <br />Dist Co Rte Post <br />BASIS OF DISCRIMINATION <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SkrX ❑ Diale lity [] Low -Income [] Nan-P;nglish Speaker <br />Provide datc(s) and place of alleged discrimination <br />Ueseribe the nature ofthe action, decision, or conditions of the alleged discrimination (Attach Extra Page. UNecessary) <br />Name of individuals (iCKnmvn) responsible For the action, decision of condition of alleged discrimination <br />Provide supporting information known to complainant in suppnrt of his/her allegation <br />Identify possible witnesses whom the complainant believes can provide factual in formation aboutlhis allegation <br />State the action requested by complainant <br />signattn'c <br />use of the Title VI Discrindr atlon Complaint }'onn is not fl a ldatory. You may submit your conrptaint in any onion mat, contains your <br />75K-49 <br />