Transit Services (e-tran)

Title VI Program and Complaint Form

The City of Elk Grove is committed to ensuring that no person is excluded from participation in or denied the benefits of its services on the basis of race, color or national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days of the alleged discrimination.

The following information is necessary to assist us in processing your complaint.  If you require any assistance in completing this form, please contact the Title VI Coordinator.

Printable Form
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The completed form must be returned to:

Title VI Coordinator
Jean Foletta
8401 Laguna Palms Way
Elk Grove, CA 95758
(916) 478-2249
jfoletta@elkgrovecity.org

Additional Resource:

FTA’s Title VI Complaint Application


Title VI Complaint Form
Your Name:
Street Address:
City/State/Zip:
Phone:
Alt Phone:
Person(s) discriminated against (if someone other than complainant):
Person Name(s):
Persons's Street Address:
Person's City/State/Zip:
Which of the following best describes the reason the alleged discrimination took place?
  Race
Color
National Origin (Limited English Proficiency)
Other:
Date of Incident:

Please describe the alleged discrimination incident. Provide the names and titles of all City of Elk Grove (or it’s Contractor MV Transportation, Inc.) employees involved, if available. Explain what happened and whom you believe was responsible:

Have you filed a complaint with any other federal, state or local agencies regarding this incident?
     Yes No
If so, list agency/agencies and contact information below:
Agency 1:
Contact Name 1:
Street Address 1:
City/State/Zip 1:
Phone 1:
   
Agency 2:
Contact Name 2:
Street Address 2:
City/State/Zip 2:
Phone 2:

The City will make every effort to address your concern within a reasonable period of time. You will be contacted by the Title VI Coordinator within ten (10) business days. If your concern pertains to an agency other than the City of Elk Grove, we will forward this form to the responsible agency.

All written complaints and responses will be retained by the City of Elk Grove for at least three years.

If the response by the Title VI Coordinator or designee does not satisfactorily resolve the concern, the complainant may appeal the decision within sixty (60) calendar days after receipt of the response to the City Manager or designee.

By clicking on "Submit" below, I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief.

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