Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement (Page 2 of 2) in pdf

EQUAL RIGHTS COMPLAINT PROCESS INFORMATION

èFor effective complaint handling, please complete and return the following information with your complaint.

Your Full Name (last, first, middle initial)

Today’s Date

Social Security Number

Not mandatory - used only for internal identification, accessibility

and accuracy of records within the Equal Rights Division.

WITNESSES: Please include the names, home addresses and telephone numbers of persons who know what happened to

you or may have seen, heard or experienced treatment similar to yours. Witnesses are not character references. They are

people who have relevant information about your complaint and are willing to cooperate in the investigation.

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AVAILABILITY: Please note below how you can be reached. (Important! You must notify the Department if you

change your address or telephone number. If we are unable to locate you, your complaint may be dismissed.)

1. What days and times are you usually

available to discuss your complaint?

2. Is there a telephone where we can reach you during the day?

If so, please provide the area code and number:

(

)

3. In case we cannot reach you, please provide the name, address and telephone number of a person who does not reside

with you but will always know where you live and how to reach you:

Name .................................................................Address.........................................................................................

City, State, ZIP Code.................................................................................Telephone (

)

SETTLEMENT INFORMATION:

At this time, what would you accept to settle your complaint? (Note: If discrimination is proven under state law you

may recover costs you incurred because of the discrimination and attorney fees. The respondent may be required to pay a

forfeiture to the State. In a civil action, punitive damages may also be sought.)

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Have

COMPLAINT INFORMATION:

you filed this charge with any other agency?

Yes

If so, name of agency:......................................................................................... Date filed: .........................................

STATISTICAL INFORMATION:

You Are:

Date of Birth:

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Male

Female

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African-American (Black)

White Nonhispanic

Asian/Pacific Islander

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Native-American/Aleutian