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    Section I:

    Section II:

    If you answered yes to the previous question, go to Section III.

    If not, please supply the name and relationship of the person for whom you are complaining.

    Section III

    RaceColorNationl Origin


    Explain as clearly as possible what happened and why you believe you were discriminated against. 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.

    Section IV

    Section V

    If yes, check all that apply:

    Federal AgencyFederal CourtState AgencyState CourtLocal Agency

    Please provide information about a contact person at the agency/court where the complaint was filed

    Section VI

    Our Partners

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