*Title VI, Environmental Justice, and Limited English Proficiency Complaint Form*

Title VI, Civil Rights Act, 1964 states “No person in the United States shall, on 
the ground of race, color or national origin, be excluded from participation in, be 
denied the benefits of, or be subjected to discrimination under any program or 
activity receiving Federal financial assistance.”  Two Executive Orders extend 
Title VI protections to Environmental Justice, which also protects persons of low 
income, and Limited English Proficiency (LEP).

Please provide the following information necessary in order to process your 
complaint. Assistance is available upon request.  Complete this form and mail or 
deliver to: City & County of Honolulu, Department of Transportation Services, 
Public Transit Division, Fixed Route Operations Branch; 650 South King Street, 3rd 
Floor, Honolulu, HI 96813.

1.  Complainant’s Name: ___________________________________________________________

2.  Address: ______________________________________________________________________

3.  City: ___________________________  State: __________  Zip Code: _______________

4.  Telephone No. (Home): _______________________  (Business): ____________________

5.  Person discriminated against (if other than complainant)

     Name: ________________________________________________________________________

     Address: _____________________________________________________________________

     City: ___________________________  State: __________  Zip Code: ______________

6.  What was the discrimination based on? (Check all that apply):

    _____ Race/Color

    _____ National Origin

    _____ Low Income

    _____ Limited English Proficiency

7.  Date of incident resulting in discrimination: _________________________________

8.  Describe how you were discriminated against.  What happened and who was 
    responsible?  For additional space, attach additional sheets of paper or use 
    back of form.

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9.  Did you file this complaint with another Federal, state, or local agency; or 
     with a Federal or state court? (Check appropriate space) ______ Yes  ______ No

     If answer is yes, check each agency complaint was filed with:

     Federal Agency ___________  Federal Court ___________  State Agency __________

     State Court ___________  Local Agency ___________  Other	___________________			

10. Provide contact person information for the agency you also filed the complaint 
     with:

     Name: ________________________________________________________________________

     Address: _____________________________________________________________________

     City: ___________________________  State: __________  Zip Code: ______________
      
     Date Filed: _____________________

11. Sign the complaint in space below.  Attach any documents you believe will 
     support your complaint.



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      Complainant’s Signature                                  Signature Date