HomeMy WebLinkAboutCity of Rexburg Title VI Complaint Form(208) 359-3020
35 North 1st East
Rexburg, ID 83440
Rexburg.org | Engage.Rexburg.org
FHWA and City of Rexburg, ID Title VI Complaint Form
Contact information of person completing this complaint:
Name_________________________________________________________________
Address_______________________________City________________Zip___________
Phone: ______________________________________________________________
Email: _______________________________________________________________
Basis of Complaint (circle all that apply):
Race
Color
National Origin
Who discriminated against you?
Name_________________________________________________________________
Name of Organization____________________________________________________
Address________________________________ City________________ Zip________
Phone_____________________________
How were you discriminated against? (Please provide specific details - attach additional pages
if more space is needed)
(208) 359-3020
35 North 1st East
Rexburg, ID 83440
Rexburg.org | Engage.Rexburg.org
Where did the discrimination occur?
Dates and times discrimination occurred?
Were there any other witnesses to the discrimination?
Name Organization/Title Work
Telephone
Home
Telephone
How would you like to see this situation resolved?
(208) 359-3020
35 North 1st East
Rexburg, ID 83440
Rexburg.org | Engage.Rexburg.org
Have you filed your complaint, grievance, or lawsuit with any other agency or court?
Who ______________________________________ When ______________________
Status (pending, resolved, etc.) _________________ Result, if known ______________
Complaint number, if known _________________________________
Do you have an attorney in this matter?
Name_________________________________ Phone____________________
Address___________________________________ City______________ Zip_______
Signed:___________________________________Date:______________
To file an FHWA Title VI discrimination complaint, contact: Rexburg City Clerk PO Box 280
Rexburg, ID 83440 clerk@rexburg.org (208) 359-3020
Title VI complaints related to Federal-aid highway programs may also be filed directly with
the following agencies:
Idaho Transportation Department Federal Highway Administration
Office of Civil Rights U.S. Department of Transportation Office of Civil Rights
11331 W. Chinden Blvd 1200 New Jersey Avenue, SE
Boise, ID 83714 8th Floor E81-105
CivilRights@itd.idaho.gov Washington, DC 20590
Phone: (208) 334-8884 Civilrights.fhwa@dot.gov
Phone: (202) 366-0693
Fax: (202) 366-1599
Federal Highway Administration, Idaho Division
3050 Lakeharbor Lane #126
Boise, ID 83703
Idaho.fhwa@dot.gov
Phone: (208) 334-1843