Complaint Form

Address *

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Are you filling out this complaint on your own behalf? *

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Address *

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Have you obtained permission to file on this person's behalf? *

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The discrimination alleged was on the basis of *

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Where did the alleged discrimination take place? *

Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons involved, including the name and contact information of persons who discriminated against you (if known). *

Please list any and all witnesses' 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? *

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Complaint Form

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