LKLP Community Action

Title VI Complaint Form

Please fill out this form in its entirety. The Agency will only process complaints that are complete.

Instructions

Fields marked * are required.
You may use the Tab key to move through the form.
If you need help completing this form, contact the Title VI Officer at 606-436-8853.
You may upload supporting files in PDF, DOC, DOCX, JPG, JPEG, or PNG format.

Section I

Name *

Address *

Telephone (Home)

Telephone (Work)

Electronic Mail Address

Accessible Format Requirements

Large Print Audio Tape TDD Other

If other, please describe

Section II

Are you filing this complaint on your own behalf? *

Yes No

If you answered “yes,” go to Section III.

If not, name of person for whom you are complaining

Relationship

Please explain why you have filed for a third party

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party

Yes No

Section III

I believe the discrimination I experienced was based on (check all that apply) *

Race Color National Origin

Date of Alleged Discrimination

Explain as clearly as possible what happened and why you believe you were discriminated against *

Describe all persons who were involved. Include the name and contact information of the person or persons who discriminated against you, if known, as well as names and contact information of any witnesses.

Section IV

Have you previously filed a Title VI complaint with this agency? *

Yes No

Section V

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? *

Yes No

If yes, check all that apply

Federal Agency Federal Court State Agency State Court Local Agency

Contact person name at the agency/court

Title

Agency/Court

Telephone

Address

Section VI

Name of Agency complaint is against *

Contact person

Title

Telephone number

Upload supporting documents

Optional. You may upload multiple supporting files. Recommended formats: PDF, DOC, DOCX, JPG, JPEG, PNG.

Additional written materials or other information you think is relevant to your complaint

Signature *

Date *

File this complaint with LKLP

Abby Little, Title VI Officer
LKLP CAC, Inc.
398 Roy Campbell Drive
Hazard, KY 41701
Email: compliance@lklp.net
Phone: 606-436-8853 · Fax: 606-435-7979

A person may also file a complaint directly with the Federal Transit Administration, FTA Office of Civil Rights, 1200 New Jersey Avenue SE, Washington, DC 20590.

LKLP is an equal opportunity employer and service provider.