Discrimination Complaint Form - State Of New York Office Of The Attorney General (Page 2 of 2) in pdf

Discrimination Complaint Form - State Of New York Office Of The Attorney General Page 2

ARE YOU AWARE OF OTHER INDIVIDUALS WHO MAY HAVE BEEN SUBJECTED TO THE ALLEGED DISCRIMINATORY

CONDUCT? IF YES, PROVIDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS, IF POSSIBLE.

HAVE YOU SOUGHT OR RECEIVED ASSISTANCE FROM THE NEW YORK STATE DIVISION OF HUMAN RIGHTS OR ANY

OTHER GOVERNMENT AGENCY? IF YES, PROVIDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS, IF POSSIBLE.

ARE YOU REPRESENTED BY A PRIVATE ATTORNEY? IF YES, PROVIDE NAME, ADDRESS, AND TELEPHONE NUMBER.

IS A COURT ACTION OR ADMINISTRATIVE PROCEEDING PENDING? IF YES, PROVIDE THE CASE NUMBER AND A COPY

OF THE COMPLAINT.

READ THE FOLLOWING BEFORE SIGNING BELOW:

NOTE: This complaint form is NOT the equivalent of filing a formal charge with the New York State Division

of Human Rights (SDHR) or the Equal Employment Opportunity Commission (EEOC).

In filing this complaint, I understand that the Attorney General is not my private attorney, but represents the public to enforce laws

designed to protect the public from patterns and practices of discrimination or discriminatory policies. I also understand that this

complaint form is not a lawsuit, but rather an informal charge by me that I have been discriminated against. I agree that the Attorney

General's Office may use its discretion to determine whether an investigation is warranted and may need to contact the person/entity

I am complaining about. If I have any questions concerning my legal rights or responsibilities, I should contact a private attorney. The

above complaint is true and accurate to the best of my knowledge.

I also understand that any false statement made in this complaint is punishable as a Class A Misdemeanor under Section 175.30

and/or Section 210.45 of the Penal Law.

Signature:

Date:

HAVE YOU ENCLOSED COPIES OF IMPORTANT PAPERS?

Return to:

State of New York

Office of the Attorney General

Civil Rights Bureau

120 Broadway, 23rd Floor

New York, NY 10271-0332

Discrimination Complaint Form - State Of New York Office Of The Attorney General Page 2