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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 all <br /> that apply. <br /> NC Department of Transportation Federal Transit Administration US Department of Transportation US Department o <br /> Justice Federal or State Court Other <br /> Have you discussed the complaint with any Orange County Transportation Service representative?If yes, provide the name, position,and date o <br /> 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 Transportation Service 600 NC Highway 86 North <br /> Hillsborough, NC 27278 OCTransportationServices@orangecountync.gov 919-245-2008 <br /> FOR OFFICE USE ONLY <br /> Date Complaint Received:_Processed by:_Case#:_ <br /> Referred to: NCDOT FTA Date Referred: <br /> ❑ ❑ <br />