Title VI Notice to the Public
UCP of Hudson County, Inc. operates its program and services without regard to race, color, or national origin in accordance with Title VI of the Civil Rights Act of 1964, as amended. Any person who believes that he or she has been aggrieved by any unlawful discriminatory practice under Title VI may file a complaint in writing to UCP of Hudson County. To file a complaint, or for more information on UCP of Hudson County’s obligations under Title VI write to: UCP of Hudson County, 721 Broadway, Bayonne, NJ 07002
or visit www.ucpofhudsoncounty.org. Transportation services provided by this agency are in part funded through federal funds received through NJ Transit and as an individual you also have the right to file your complaint to both UCP of Hudson County as well as the Federal Transit Administration. Complaints may also be filed with the Federal Transit Administration in writing and may be addressed to: Title VI Program Coordinator, East Building, 5th Floor-TCR,
US Department of Transportation, Federal Transit Administration, Office of Civil Rights, 1200 New Jersey Ave., SE, Washington DC 20590
If information is needed in another language, contact 201-436-2200.
Título VI aviso al público
UCP of Hudson County opera sus programas y servicios sin importar raza, color o origen nacional según el título VI de la ley de derechos civiles de 1964 enmendada. Cualquier persona que cree que él o ella ha sido agraviado por cualquier práctica discriminatoria ilegal bajo el título VI puede presentar una queja por escrito al oficial de cumplimiento corporativo de UCP of Hudson Country. Para presentar una queja o para obtener más información sobre las obligaciones de capacidades bajo el Titulo VI escribir: UCP of Hudson County, 721 Broadway, Bayonne, NJ 07002 o visita www.ucpofhudsoncounty.org. Servicios de transporte prestados por esta agencia son total o parcialmente financiado mediante fondos federales recibidos a través de NJ TRANSIT y como individuo también tiene el derecho a presentar su queja con la Administración Federal de tránsito escribiendo a: Coordinadora del programa Título VI, edificio este, 5 º piso – TCR, los E.E.U.U. Departamento del transporte, FTA, Office of Civil Rights, 1200 New Jersey Avenue, SE, Washington, DC 20590.
Si necesita información en otro idioma, comuníquese con: 201-436-2200.
Note: This information is posted in all FTA funded vehicles used to operate UCP of Hudson County’s Transportation Program and on UCP of Hudson County’s website. It is also provided in large print format.
Title VI Complaint Form
Note: The following information is needed to assist in processing your complaint.
A. Complainant’s Information:
Name:
Address:
City/State/Zip Code:
Telephone Number:
Email Address:
Accessible Format Requirements? (Select one or more)
o Large Print
o TDD
o Audio Tape
o Other:
B. Person discriminated against (if someone other than complainant):
Name:
Address:
City/State/Zip Code:
Telephone Number (Work):
Email Address:
Relationship to the person for whom you are complaining:
Please explain why you have filed for a third party:
Please confirm that you have obtained the permission of the aggravated party if you are filing on behalf of a third party.
o Yes
o No
C. Which of the following best describes the reason you believe the discrimination took place?
o Race
o Color
o National Origin
o Other:
D. On what date(s) did the alleged discrimination take place?
Date: Date:
Date: Date:
Date: Date:
Date: Date:
Other:
E. Please describe the alleged discrimination. Explain what happened and whom you believe was responsible. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If additional space is needed, add a sheet of paper.
F. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? List all that apply.
Federal Agency
Federal Court
State Agency
State Court
Local Agency
If you have checked above, please provide information about a contact person at the agency/court where the complaint was filed.
Name:
Address:
City/State/Zip Code:
Telephone Number (Home):
Telephone Number (Work):
Email Address:
G. Please sign below. You may attach any written material or other information that you think is relevant to your complaint.
______________________________________________ _______________________
Signature Date
Attachments: Yes No
H. Submit form and any additional information to:
United Cerebral Palsy of Hudson County
Human Resources Department
721 Broadway
Bayonne, NJ 07002