Form Erd-4206a - Discrimination Complaint Fair Employment

EQUAL RIGHTS COMPLAINT PROCESS INFORMATION

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

Today’ s Date

Your Full Name (last, first, middle initial)

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 phone 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 phone 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 phone 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..................................................................................Telephone (

)

SETTLEMENT INFORMATION: Complete applicable spaces below if terminated or not hired or promoted:

Job Title at Termination

Rate of Pay at Termination

Hours worked weekly

If Terminated:

Position Applied For

Rate of Pay

Hours Per Week

Present Job Title

If Not Hired

or Promoted:

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

may recover lost pay related to the discrimination, attorney fees, reinstatement and related remedies. If discrimination is

shown under federal law, additional damages may be available.)

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COMPLAINT INFORMATION:

Have you filed this charge with any other agency?

Yes

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

EMPLOYER INFORMATION

Type of Business................................................................................................................................................................

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Approximate number of employees at all locations:

Less than 15

101 to 200

More than 500

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15 to 100

201 to 500

STATISTICAL INFORMATION:

Date of Birth:

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