COUNCIL OF GOVERNMENTS OF THE CENTRAL NAUGATUCK VALLEY Title VI Policy Statement The Council of Governments of the Central Naugatuck Valley (COGCNV), as a recipient and subrecipient of federal financial assistance, works to ensure full compliance with Title VI of the Civil Rights Act of 1964, as amended, and related statutes and regulati on in all COGCNV programs and activities. The COGCNV is committed to ensuring that no person is excluded from participation, denied benefits, or otherwise subjected to discrimination under any program or activity, on the basis of race, color, or national origin. Anyone who believes that he or she has been subjected to discrimination or retaliation based on their race, color, or national origin may file a Title VI complaint. Complaints maybe filed directly to COGCNV or to the Federal Funding agency. Complaints must be filed in writing and signed by the complainant or a representative and should include the complainant’s name, address, and telephone number or other means by which the complain ant can be contacted. Complaints must be filed within 180 days of the date of the alleged discriminatory act. To request additional information on COGCNV’s non ‐discrimination obligations to file a Title VI complaint, please submit your request or complaint in writing to: Executive Director Council of Gove rnments of the Central Naugatuck Valley 60 North Main Street, Third Floor Waterbury, CT 06702 Complaint forms can be obtained online at the COGCNV website: www.cogcnv.org Federal Transit Administration (FTA) Title VI complaints may be filed directly to: Federal Transit Administration Title VI Program Coordinator East Building, 5 th Floor, TCR 1200 New Jersey Avenue, SE Washington, DC 20590 Federal Highway Administration (FHWA) Title VI complaints may be filed directly to: Federal Highway Administration Investigations & Adjudication Team Director FHWA Office of Civil Rights 1200 New Jersey Avenue, SE, Suite E ‐81 Washington, DC 20590 APPENDIX A: TITLE VI POLICY STATEMENT AND COMPLAINT FORM COUNCIL OF GOVERNMENTS CENTRAL NAUGATUCK VALLEY TITLE VI DISCRIMINATION COMPLAINT FORM Complainant’s Name: ____________ _____________ Street Address: ______________ ________________ City/State/Zip: ______________________________ Phone: _________________ Discrimination because of: Race Color National Origin (check applicable box[es]) Please provide the date(s) and location of the alleged discrimination, the name(s) of the individual(s) who allegedly discriminated against you including their titles (if known). ____________________________________ _______________________________________________ ____________________________________ _______________________________________________ ____________________________________ _______________________________________________ Please provide the names, addresses, and telep hone numbers of any witnesses. ____________________________________ _______________________________________________ ____________________________________ _______________________________________________ ____________________________________ _______________________________________________ Explain as briefly and as clearly as possible what happened, how you feel that you were discriminated against, and who was involved. Please include how other persons were treated differently from you. ____________________________________ ________________________________ _______________ ____________________________________ _______________________________________________ ____________________________________ _______________________________________________ Signature: ____________________ Date: _____________ Please print name _______ ________________ You may use additional sheets of paper if necessary. Also include any written materials pertaining to your complaint. Deliver or mail this form to: Peter Dorpalen Executive Director, COGCNV, 60 North Main Street, 3 RD Floor Waterbury, CT 06702 or email to: pdorpalen@cogcnv.org , or fax to Attn: P. Dorpalen at 203 ‐756 ‐7688.