Title VI Complaint Form

The Menominee Indian Tribe of Wisconsin Title VI Complaint Procedure is made available in the following locations:

  • Agency website, either as a reference in the Notice to Public or in its entirety
  • Hard copy in the central office
  • Available in appropriate languages for LEP populations, meeting the Safe Harbor Threshold.
Section I
Name:
Address:
Telephone (Home): Telephone (Work):
Electronic 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 a filing on behalf of a third party. Yes No
Section III
I believe the discrimination I experienced was based on (check all that apply):
Race Color National Origin
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 the names and contact informatio of any witnesses. If more space is needed, please use the back of this form.
Section IV
Have you previously filed a Title VI complaint with this agency? Yes No
Section V
Have you filed this complaint with any other Federal, State, or local agency, or with and Federal or State Court?
Yes No
If yes, check all that apply:
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 the names and contact informatio of any witnesses. If more space is needed, please use the back of this form.

You may attach any written materials or other information that you think is relevant to your complaint.


Signature and date required below



Signature



Please submit this form in Person at the address below, or mail this form to:


Menominee Indian Tribe of Wisconsin

Department of Transit Services - Title VI Coordinator

W2727 Our Children's Road

PO BOX 910

Keshena WI 54135