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DocuSign Envelope ID:3FDDF183-DEOC-45F5-AE17-OB9CF99E613F <br /> DISCRIMINATION COMPLAINT FORM <br /> Have you filed,or intend to file,a complaint regarding the matter raised with any of the following?If yes, please provide the filing dates.Check <br /> all that apply. <br /> ❑ NC Department of Transportation <br /> ❑ Federal Transit Administration <br /> ❑ US Department of Transportation <br /> ❑ US Department of Justice <br /> ❑ Federal or State Court <br /> ❑Other <br /> Have you discussed the complaint with any Orange County Public Transportation representative?If yes, provide the name, position,and date <br /> of discussion. <br /> Please provide any additional information that you believe would assist with an investigation. <br /> Briefly explain what remedy,or action,are you seeking for the alleged discrimination. <br /> **WE CANNOT ACCEPT AN UNSIGNED COMPLAINT. PLEASE SIGN AND DATE THE COMPLAINT FORM BELOW. <br /> COMPLAINANT'S SIGNATURE DATE <br /> MAIL COMPLAINT FORM TO: <br /> Orange County Public Transportation <br /> 600 NC Highway 86 North <br /> Hillsborough, NC 27278 <br /> OCTransportationServices@orangecountync.gov <br /> 919-245-2008 <br /> FOR OFFICE USE ONLY <br /> Date Complaint Received: <br /> Processed by: <br /> Case#: <br /> Referred to: ❑NCDOT ❑FTA Date Referred: <br /> 18 <br />