2. Complainant Information
4. Name
6. Address1
8. Address2
10. City
11. State
12. Zip
14. Primary Phone Number
15. Secondary Phone Number
19. Information of Person Discriminated Against (complete only if different from the complainant)
21. Name
23. Address1
25. Address2
29. Government, or organization or institution which you believe has discriminated:
31. Name
33. Address1
35. Address2
37. City
38. State
39. Zip
41. Phone Number
42. Date of Descrimination
46. Have efforts been made to resolve this complaint?

    1. Yes

    1. No
47. If 'Yes', What is the status of the grievance?
51. Has the complaint been filed with the Department of Justice or any other Federal, State, or local civil rights agency or court?

    1. Yes

    1. No
53. If yes:
55. Agency or Court
56. Contact Person
58. Address1
60. Address2
62. City
63. State
64. Zip
66. Phone Number
67. Date Filed
71. Do you intend to file with another agency?

    1. Yes

    1. No
73. If yes:
75. Agency or Court
76. Phone Number
78. Address1
80. Address2
82. City
83. State
84. Zip
88. Electronic Signature
    By entering your name in this box, you agree all information provided in this form is correct to the best of your knowledge. This field acts as an electronic signature.
89. Date
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit

* indicates a required field