FHWA Office of Civil Rights

Section I

* I believe that I have been (or someone else has been) discriminated against on the basis of:

Race
Color
National Origin

Section II

*First Name:   *State:
*E-mail Address:

Section III

Are you filing this complaint on your own behalf?
Yes No

If not, please supply the name and relationship of the person for whom you are complaining:

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

Are you represented by legal counsel for this matter?
Yes No

If yes, please supply name and contact information:

Have you previously filed a civil rights complaint with FHWA?
Yes No

Section IV

*Name of public entity complaint is against:

Section V

Have you filed this complaint with any of the following agencies?
U.S. Department of Justice
U.S. Department of Transportation
Your State's Department of Transporation
Local Public Agency
U.S. Equal Employment Opportunity Commission

Other:

Have you filed a lawsuit regarding this complaint?
Yes No
If yes, please provide the case number:

Section VI

*Please Include Details of Your Complaint Below. FHWA will contact you to request any additional documentation you may want to submit on behalf of your complaint.

Important: We cannot accept your complaint without a signature, so please type your first name.

*Signature: