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Section I
Name
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First Name
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Last Name
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Address
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State
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Section II
Are you filing this complaint on your own behalf?
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No
Please tell us the name and relationship to you of the person for whom you are completing this form.
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Please explain why you are completing this form for another person.
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Please confirm that you have obtained the aggrieved party's permission if you are submitting this form on behalf of another person.
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Yes
No
Section III
I understand that the purpose of many Via services and programs is to address the mobility challenges some individuals face because of age or disability. Apart from any eligibility requirements based on age or disability for receiving services, I believe that I experienced discrimination with regard to receiving the benefits of programs and/or services from Via Mobility Services based on the following (check all that apply):
*
Race
Color
National origin (Ancestry)
Religion (Creed)
Gender
Gender expression
Age
Disability
Marital status
Sexual orientation
Military status
Other:
Other Value
Date of Alleged Discrimination
*
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
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11
12
13
14
15
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26
27
28
29
30
31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
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 information of any witnesses.
*
Section IV
Signature
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Date/Time
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Month
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Aug
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Oct
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Day
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31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
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