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25 <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 OCTS representative?Ityes. provide the name. position. and date 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 ANTE <br /> MAIL COMPLAINT FORM TO: <br /> Orange County Transportation Services <br /> 600 NC 86 <br /> Hillsborough_NC 27278 <br /> (919)245-2004 <br /> FOR OFFICE USE ONLY <br /> Date Complaint Received: <br /> Processed by: <br /> Case# <br /> Referred to: ❑NCOOT ❑FTA Date Referred <br /> 181Page <br />