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COMPLAINT FORM

Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the ground of
race, color or national origin, disability, sex, age, low income status or limited English proficiency, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” If you feel you have been discriminated against in transit services, please provide the following information in order to assist us in processing your complaint and send it to:

Pontem Contractors Inc.
ATTN: Alma Samuels, Title VI Coordinator

4050 Rockville Road
Indianapolis, IN 46222
Phone: 317-484-1500
Fax: 317-484-1561

NAME		EMAIL
HOME PHONE		CELLPHONE
ADDRESS
City	State		Zip Code

Person discriminated against:
ADDRESS
City	State			Zip Code

Please check off why you believe the discrimination occurred:

What was the date of the alleged discrimination?
Where did the alleged discrimination take place?
Please describe the circumstances as you saw it:
Please list any and all witnesses’ names and phone number:
Witness 1 Name		Phone 1
Witness 2 Name		Phone 2
Witness 3 Name		Phone 3
Witness 4 Name		Phone 4
What type of corrective action would you like to see taken?
Please attach any documents you have which support the allegation.


Name with Signature			Date Today