Complaint Form

Any person who believes they have been aggrieved by an unlawful discriminatory practice under Title VI has a right to file a formal complaint with Gwinnett County DOT. The complaint must be in writing using this form and must be filed with the Gwinnett DOT Title VI Coordinator within 180 calendar days following the date of the alleged discrimination. The following information is necessary to assist Gwinnett DOT in processing your complaint. Please complete all sections of this form and mail to :

Gwinnett DOT Title VI Coordinator
Gwinnett County Department of Transportation
75 Langley Drive
Lawrenceville, GA 30046

Should you require any assistance in completing this form, please contact the Gwinnett DOT Title VI Coordinator at 770-822-7400.

Fields marked are required.

1. Complainant's information

Name

Street Address

Apt / Suite / Other

City

State

Zip

Telephone Number

Email address

2. Person discriminated against (if other than the complainant)

Name

Street Address

Apt / Suite / Other

City

State

Zip

Telephone Number

Email address

3. Which of the following best describes the reason you believe the alleged discrimination took place?

Race

Color

Sex

National Origin

Disability

Age

4. On what date did the alleged discrimination take place?

5. In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.

Max 5000 characters. Characters left

6. Have you filed this complaint with any other federal, state or local agency, or with any federal or state court?

Yes

If yes,check all that apply:

Federal agency

Federal court

State agency

State court

Local agency

7. Please provide information for a contact person at the agency or court where the complaint was filed.

Name

Street Address

Apt / Suite / Other

City

State

Zip

Telephone Number

Email Address

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DOT Title VI Complaint Form

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DOT Title VI Complaint Form

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