Discrimination Complaint Form - State Of New York Office Of The Attorney General

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Office of the Attorney General
Helpline 1(800) 771-7755
For Hearing Impaired TDD 1 (800) 788-9898
ATTORNEY GENERAL ERIC T. SCHNEIDERMAN
STATE OF NEW YORK
OFFICE OF THE ATTORNEY GENERAL
DISCRIMINATION
CIVIL RIGHTS BUREAU
COMPLAINT FORM
120 BROADWAY, 23RD FLOOR
NEW YORK, NEW YORK 10271-0332
TEL: (212) 416-8250
FAX: (212) 416-8074
WEB SITE:
1. PLEASE TYPE OR PRINT CLEARLY IN DARK INK.
2. MAKE SURE YOU ENCLOSE COPIES (NOT ORIGINALS) OF IMPORTANT PAPERS CONCERNING YOUR COMPLAINT.
PERSON FILING COMPLAINT:
Your Name ______________________________________________________________________________________________
Street Address ___________________________________________________________________________________________
City/State/Zip ____________________________________________________________________________________________
Phone __________________________________________________________________________________________________
PERSON/ENTITY YOU ARE COMPLAINING ABOUT:
Name __________________________________________________________________________________________________
Street Address ___________________________________________________________________________________________
City/State/Zip ____________________________________________________________________________________________
Phone __________________________________________________________________________________________________
NATURE OF COMPLAINT:
[ ] EMPLOYMENT
[ ] HOUSING
[ ] EDUCATION
[ ] PLACE OF BUSINESS
[ ] CREDIT/LENDING
[ ] REPRODUCTIVE RIGHTS
[ ] OTHER _____________
YOU WERE DISCRIMINATED AGAINST BECAUSE OF YOUR:
[ ] RACE
[ ] SEX
[ ] RELIGION
[ ] NATIONAL ORIGIN
[ ] COLOR
[ ] DISABILITY
[ ] AGE
[ ] SEXUAL ORIENTATION
[ ] CREED
[ ] MILITARY STATUS
[ ] MARITAL STATUS
[ ] GENETIC PREDISPOSITION
[ ] OTHER _____________
PLEASE EXPLAIN THE FACTS UNDERLYING YOUR COMPLAINT (feel free to attach additional pages):
(OVER)

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