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Title VI Complaint Form
The City of Modesto is committed to ensuring that no person is excluded from participation in or denied the benefits of it's services on the basis of race, color, national origin, age, gender, or disability pursuant to Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days from the date of the alleged discrimination.

The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact Angela Swanson, the Title VI Transit Compliance Officer at the City of Modesto Transit Office by calling 209-577-5201 or email.
Your Name*
Phone Number*
Other Number*
Street Address*
City*
Zip Code*
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Have you filed a complaint with any other federal, state, or local agencies?*
1. Yes
2. No
List Agency / Agencies and Contact Information*
Electronic Signature Agreement*
By checking the "I agree" box below, you agree and acknowledge that 1) your submitted form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree that I have read the above charge and it is true to the best of my knowledge.
Signature*

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