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September 2024 8 of 28 Section 5: Title VI Complaint Form Greene County Transit Title VI Complaint Form Section I: Name: Address: Telephone (Home): Telephone (Work): E‐Mail Address: Accessible Format Requirements? Large Print Audio Tape TDD Other Section II: Are you filing this complaint on your own behalf? Yes* No *If you answered "yes" to this question, go to Section III. If not, please supply the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. Yes No Section III: ---PAGE BREAK--- September 2024 9 of 28 I believe the discrimination I experienced was based on (check all that apply): Title VI: [ ] Race [ ] Color [ ] National Origin Other (specify): Date of Alleged Discrimination (Month, Day, Year): Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please use the back of this form. Section IV Have you previously filed a Civil Rights related complaint with this agency? Yes No Section V Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? [ ] Yes [ ] No If yes, check all that apply: [ ] Federal Agency: [ ] Federal Court [ ] State Agency [ ] State Court [ ] Local Agency If marked Yes in Section V, please provide information about a contact person at the agency/court where the complaint was filed. Name: Title: Agency: ---PAGE BREAK--- September 2024 10 of 28 Address: Telephone: Section VI Name of agency complaint is against: Contact person: Title: Telephone number: You may attach any written materials or other information that you think is relevant to your complaint. Signature and date required below Signature Date Please submit this form in person at the address below, or mail this form to: Greene County Transit Chris Edwards, Title VI Coordinator 1034 Silver Drive, Suite 201, Greensboro, GA 30642 706‐453‐7716 Email: [EMAIL REDACTED];