Civil Rights Complaint - New York Us Attorney'S Office

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United States Attorney’s Office
Southern District of New York
Civil Rights Unit
Civil Rights Complaint Form
The Civil Rights Unit of the United States Attorney’s Office is charged with enforcing the federal civil rights laws within
the Southern District of New York, which includes Bronx, Dutchess, New York, Orange, Putnam, Rockland, Sullivan, and
Westchester counties. We therefore welcome information from the public that brings to our attention possible violations of our
Nation’s civil rights laws.
Person Filing complaint
Person/Entity you are filing complaint about:
:
__________________________________________
_______________________________________________
Name
Name of Person or Entity
__________________________________________
_______________________________________________
Address
Address
__________________________________________
_______________________________________________
Address (Line 2)
Address (Line 2)
____________________________ _____________
________________________________ ______________
City, State
Zip
City, State
Zip
__________________ ______________________
_____________________ ________________________
County
Phone
County
Phone
Nature of Alleged Civil Rights Violation:
[ ] Disability Rights
[ ] Fair Housing
[ ] Voting Rights
[ ] Educational Opportunities
[ ] Law Enforcement Misconduct [ ] Other: _______________
[ ] Employment Discrimination
[ ] Prisoner/Institutional Rights
Please clearly describe the violation of the civil rights laws that you would like to bring to our attention.
Include as much information as possible, including the date, place, nature of incident, and contact
information for any witnesses (do not send original documents):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________
<Attach additional page(s) if necessary>

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