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TITLE VI DISCRIMINATION COMPLAINT <br />PERSONAL INFORMATION NOTICE <br />Pursuant to the Federal Privacy Act (RL 99579) and the Information Practices Act of 1977 (clvll Code Seailons 1798, at ser.), nallce he hereby given for the request or <br />personal Information by this form. The requested personal Infmmblloh Is voluhlary. The principal purpose of the voluntary infarmalion Is to facilitate the processing of Ihie form. <br />The Fall.. to p.?do all or any pad of the requested Information may delay processing of this form. No disclosure of pemonal information will be made unless penniesibio <br />under Article e, &oclion 1798.24 of the IPA of 1977. Each Individual has the right upon requeel and proper Ide aiflwtion, to inspect all personal information In any rnemd <br />ainlai ad oa the ladryd.al by an Marauding articular, Direct any In uldes on infarmalion maintenance to your IPA more. <br />Dist Co Rte Post <br />BASIS OF DISCRIMINATION <br />❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑ SEX ❑ Diability ❑ Low -Income ❑ Nan -English Speaker <br />Provide date(s) and place of alleged discrimination <br />Describe the nature of the action, decision, of conditions of the alleged discrimination (Attach Extra Page. If Necessary) <br />Name of individuals (if Known) responsible for the action, decision or condition of alleged <br />Provide supporllag information known to eomplaivar7 In support of hls/har allegation <br />Identify possible witnesses Whom the complainant believes can provide factual information about this allegation <br />Stem <br />NOTE, Thcuse of that, Title VI Discrimination Complaint form is not mandatory. you may submit your complaint in any fomr that contains your <br />signature <br />75P-38 <br />