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Are you filing out this complaint on your own behalf?
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Name of Person Filling Complaint
Address
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State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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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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