Civil Rights Complaint - New York Us Attorney'S Office Page 2
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1
2Do you believe that the violation of civil rights described in this complaint is part of, or results from,
a policy, pattern, or practice on the part of the person or entity named above? If so, please describe the
policy, pattern, or practice in detail and identify others who you believe were subjected to the same or
similar treatment:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Are you represented by an attorney in this matter? [ ] Yes [ ] No
If yes, please provide name of
attorney, address and phone number.
Name _______________________________________________
Phone ________________________
Address _____________________________________________________________________________
Have you filed a lawsuit concerning this matter? [ ] Yes [ ] No
If yes, please provide the case
name, court in which the case was brought, and the status of the case.
____________________________________________________________________________________
____________________________________________________________________________________
Have you filed a complaint about this matter with any other federal, state, or local agency?
[ ] Yes
[ ] No
If yes, please list the agency, contact person, phone, and status of the complaint.
____________________________________________________________________________________
____________________________________________________________________________________
Although the volume of information we receive from concerned members of the public prevents us from
responding to every complaint we receive, be assured that we will carefully consider the information you have
provided us to determine whether a violation of the federal civil rights laws may have occurred and, if so,
whether this Office has enforcement authority with respect to such a violation. If we determine that your
complaint raises a potential violation of federal civil rights laws that would be within the jurisdiction of this
Office to investigate and that further information from you is necessary for our investigation, you will be
contacted.
***S
UBMITTING A COMPLAINT TO THIS OFFICE HAS NO EFFECT ON ANY STATUTE OF LIMITATIONS THAT
. B
MIGHT APPLY TO ANY CLAIM YOU MAY HAVE
Y SUBMITTING THIS COMPLAINT FORM YOU HAVE NOT
,
O
COMMENCED A LAWSUIT OR OTHER LEGAL PROCEEDING
AND THIS
FFICE HAS NOT INITIATED A SUIT OR
. I
PROCEEDING ON YOUR BEHALF
F YOU BELIEVE YOUR CIVIL RIGHTS HAVE BEEN VIOLATED AND YOU
,
.
INTEND TO SUE FOR MONEY OR OTHER RELIEF
YOU SHOULD CONTACT A PRIVATE ATTORNEY
Signature: __________________________________________________ Date: __________________
Send this completed complaint form to the following address:
Chief, Civil Rights Unit
United States Attorney’s Office
Southern District of New York
86 Chambers Street, 3
rd
Floor
New York, NY 10007
(212) 637 - 2750 (fax)
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