Name (first, middle, and last):

E-mail Address:

Address:

City:

State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. of Col. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Fed. States Micronesia Guam Marshall Islands North Mariana Is. Puerto Rico Virgin Islands Other (Use Address Lines)

Zip Code:

Home Telephone No.

Work Telephone No.

Cellular Telephone No.

Name of Complainant

Date (month, day, year)

Person You Believe Discriminated Against You ("Respondent")

Name (first, middle, and last):

Title

Name of Company

Address:

City:

State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. of Col. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Fed. States Micronesia Guam Marshall Islands North Mariana Is. Puerto Rico Virgin Islands Other (Use Address Lines)

Zip Code:

Home Telephone No.

Work Telephone No.

Cellular Telephone No.

Agency (if applicable):

Date of alleged Discrimination:

Complaints of discrimination must be filed within 180 days of the date
of the discriminatory act. If the alleged act of discrimination occurred
more than 180 days ago, please explain your delay in filing this complaint.

The alleged discrimination was based on:

: Race : Disability : Color : Ancestry : Age

: Retaliation : Gender : Religious Affiliation : National Origin

I believe Respondent discriminated against me due to (brief description):

Describe the alleged act(s) of discrimination:

Have you filed a complaint alleging the same discrimination with another state or federal agency?

: Yes

: No

If yes, please provide the following information for each agency:

Name of the Agency

Date complaint filed (month, day, year)

Case number assigned to your complaint

Current status of your complaint

Individuals with Additional Information About Your Complaint

Name of Witness 1 (first, middle, and last)

Title

Name of Company

Address:

City:

State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. of Col. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Fed. States Micronesia Guam Marshall Islands North Mariana Is. Puerto Rico Virgin Islands Other (Use Address Lines)

Zip Code:

Home Telephone No.

Work Telephone No.

Cellular Telephone No.

Include a brief description of the relevant information the witness
may provide to support your complaint of discrimination.

Name of Witness 2 (first, middle, and last)

Title

Name of Company

Address:

City:

State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. of Col. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Fed. States Micronesia Guam Marshall Islands North Mariana Is. Puerto Rico Virgin Islands Other (Use Address Lines)

Zip Code:

Home Telephone No.

Work Telephone No.

Cellular Telephone No.

Include a brief description of the relevant information the witness
may provide to support your complaint of discrimination.

Name of Witness 3 (first, middle, and last)

Title

Name of Company

Address:

City:

State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Dist. of Col. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Fed. States Micronesia Guam Marshall Islands North Mariana Is. Puerto Rico Virgin Islands Other (Use Address Lines)

Zip Code:

Home Telephone No.

Work Telephone No.

Cellular Telephone No.

Include a brief description of the relevant information the witness
may provide to support your complaint of discrimination.

How would you like your complaint to be resolved?

How did you learn about your right to file a discrimination complaint with INDOT?

: Official Complaint (This box will serve as an official signature).

: Inquiry (No signature required) This office will seek informal resolution.

Indiana Department of Transportation
Title VI/ADA Administrator
100 N. Senate Ave. Room N750
Indianapolis, IN 46204
Phone: (317) 234-6142