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:     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: , or  fax  to  Attn:  P.  Dorpalen  at  203 ‐756 ‐7688.