Article Section Breadcrumbs INDOTDoing Business with INDOTEconomic OpportunityEconomic Opportunity Division Current: Online External Complaint Form Online External Complaint Form Use this online version of State Form 54516 (1-11) to file an External Complaint of Discrimination under Title VI of the Civil Rights Act of 1964 and Related Statutes. Your Information ("Complainant") Name (first, middle, and last): E-mail Address: Address: City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDist. of Col.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMissouriMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFed. States MicronesiaGuamMarshall IslandsNorth Mariana Is.Puerto RicoVirgin IslandsOther (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: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDist. of Col.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMissouriMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFed. States MicronesiaGuamMarshall IslandsNorth Mariana Is.Puerto RicoVirgin IslandsOther (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: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDist. of Col.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMissouriMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFed. States MicronesiaGuamMarshall IslandsNorth Mariana Is.Puerto RicoVirgin IslandsOther (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: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDist. of Col.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMissouriMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFed. States MicronesiaGuamMarshall IslandsNorth Mariana Is.Puerto RicoVirgin IslandsOther (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: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDist. of Col.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMissouriMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFed. States MicronesiaGuamMarshall IslandsNorth Mariana Is.Puerto RicoVirgin IslandsOther (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 925 Indianapolis, IN 46204 Phone: (317) 232-3019 Online Services Traffic Conditions Report a Concern Notice of Tort Claim Form Indiana GIS Atlas Rules.IN.gov More IN.gov Online Services IN.gov Subscriber Center