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Complaint Form
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Accessible format of Form Needed? Check all that apply
Large Print
Audio Tape
TDD
Other
other
Are you filing out this complaint on your own behalf?
Yes
No
Name of Person Filling Complaint
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Telephone
Email
Your relationship to this person
Have you obtained permission to file on this person's behalf?
Yes
No
The discriminination alleged was on the basis of
Race
Color
National Origin
Other
Other
Date of alleged discrimination
Where did alleged discrimination take place?
Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons involved, include name and contact information of persons who discriminated against you (if known)
Please list any and all witness' names and contact information.
What type of corrective action would you like to see taken?
Have you filed a complaint with any other Federal, State or local agency/court?
Yes
No
Federal, State or local agency/court
OFed. Agency
Fed. Court
State agency
State Court
Local Agency
Local Court
OFed. Agency
Fed. Court
State agency
Local Agency
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