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☐ Yes ☐ No If yes, check all that apply: ☐ Federal Agency: ☐ Federal Court: ☐ State Agency: ☐ State Court: ☐ Local Agency: Provide information for the contact person at the agency/court where the complaint was filed. Name and Title: Agency: Address: Telephone: You may attach any written materials or other information that you think is relevant to your complaint. Signature and date required below. _____________________________________ ________________________ Signature Date Please submit this form by mail, email or in person to the address below. Town of Hamburg Tara Rinaldi 6100 South Park Ave Hamburg NY 14075 Phone 716-649-6111 x2386 [email protected] This complaint may also be filed directly with the New York State Department of Transportation, Office of Civil Rights, 50 Wolf Road, 6th Floor, Albany, NY 12232, (518) 457-1129 Fax (518) 549-1273, [email protected] or the Federal Transit Administration, Office of Civil Rights, Attention: Title VI Program Coordinator, East Building, 5th Floor-TCR, 1200 New Jersey Ave., SE Washington, DC, 20590. Town of Hamburg Title VI Plan Page vi Open-Door Services 192