Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement printable pdf download

IMPORTANT!!

PLEASE READ ALL INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING

he information you provide may be used by other government agency programs [Privacy Law, s. 15.04 (1)(m)].

State of Wisconsin

ERD Case #

Discrimination Complaint

Department of Workforce Development

Equal Rights Division

Public Accommodation or Amusement

TYPE OR PRINT IN BLACK INK

1. Your name, street address, city, state, ZIP code

2. Respondent name, street address, state, and ZIP code.

(Name of the business you believe discriminated against You). If

more than one respondent, list each separately.

Your Telephone Number (include area codes):

Home (

)

Work

(

)

4. Respondent Telephone Number

3. Your complaint may be filed with another

(include area code):

(

)

agency unless you write “no” here. See

#3 on reverse side for more details.

__________

5. County in which the

discrimination occurred:

6. BASIS: You must list a basis for your complaint.

(For example: “sex-female,” “race-African American,” “disability-visual

impairment,” “sexual orientation-homosexual,” etc.)

What is the basis for your complaint? ......................................................................................................................

7. STATEMENT: What did the respondent do? List each action that, you believe, discriminated against you. (For example: I

was denied access or services, charged a higher than regular rate, etc.) Then, tell us why you believe you were treated

differently because of the basis you listed above.

.....................................................................................................................................................................................

8. DATES:

When did the above action(s) first happen? (mo/day/yr) ............................................................................................

On what date did it last happen?

(mo/day/yr) ............................................................................................

For Office Use

By my signature below, I acknowledge that I have read the complaint. That to the best of

my knowledge, information and belief, the complaint is true and correct; and that the

complaint is not being used for any improper purpose such as to harass the party against

whom the complaint is filed.

............................................................................................................................

Signature of complainant or authorized representative

Sworn To Before Me On (mo/day/yr):

My Commission Expires:

Notary Public Signature (affix seal):

ERD-10241 (R. 12/2000)

Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement

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