Title VI, Environmental Justice, and Limited 
English Proficiency Complaint Form

Title VI, Civil Right Act, 1964 states “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”  Two Executive Orders extend Title VI protections to Environmental Justice, which also protects persons of low income, and Limited English Proficiency (LEP).

Please provide the following information necessary in order to process your complaint. Assistance is available upon request.  Complete this form and mail or deliver to: City & County of Honolulu, Department of Transportation Services, Public Transit Division, Fixed Route Operations Branch; 650 South King Street, 3rd Floor, Honolulu, HI  96813.

1.  Complainant’s Name: ____________________________________________

2.  Address: ______________________________________________________

3.  City: ______________________ State: _________ Zip Code: ____________

4.  Telephone No. (Home): ______________ (Business): __________________

5.  Person discriminated against (if other than complainant)

     Name: ________________________________________________________

     Address: ______________________________________________________

     City: ______________________ State: _________ Zip Code: ____________

6.  What was the discrimination based on? (Check all that apply):

  ________ Race/Color

  ________ National Origin

_________ Low Income

_________ Limited English Proficiency

7.  Date of incident resulting in discrimination: ___________________________

8.  Describe how you were discriminated against.  What happened and who was         
     responsible? For additional space, attach additional sheets of paper or use 
     back of form.

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9.  Did you file this complaint with another federal, state, or local agency; or with 
     a federal or state court? (Check appropriate space)_______Yes ________ No

     If answer is yes, check each agency complaint was filed with:

     Federal Agency ________  Federal Court _________  State Agency _______

     State Court _________  Local Agency _________  Other				

10. Provide contact person information for the agency you also filed the 
      complaint with:

      Name: _______________________________________________________

      Address: _____________________________________________________

      City: ______________________ State: _________ Zip Code: ____________
      
      Date Filed: 					

11. Sign the complaint in space below.  Attach any documents you believe will
       support your complaint.

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      Complainant’s Signature				Signature Date