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* 1. Type of Civil Rights complaint:

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* 2. Are you filing this complaint on your own behalf?

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* 3. If no, why have you filed for a third party?

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* 4. Please confirm you have the permission to submit complaint on behalf of a third-party.

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* 5. What is your relationship to the person for whom you are filing the complaint?

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* 6. Date of Occurrence

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* 7. Time of Occurrence

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* 8. Route Number

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* 9. Boarding location

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* 10. Direction of travel

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* 11. Destination

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* 12. Vehicle number

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* 13. Driver's name

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* 14. Driver's badge number

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* 15. Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons involved including the names and contact information of any witnesses and of those you believe discriminated against you.

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* 16. First name

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* 17. Last name

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* 18. Address line 1

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* 19. Address line 2

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* 20. City

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* 21. State

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* 22. Zip

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* 23. Phone

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* 24. Email

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* 25. UTA staff would like to reach out to you regarding your concerns. Would you like to be contacted by a member of UTA staff once our investigation is complete?

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* 26. Would you like UTA to contact you once our investigation is complete?

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