STATE OF HAWAII
DEPARTMENT OF HUMAN SERVICES
COMPLAINT WITHDRAWAL FORM
hereby WITHDRAW the Discrimination
Complaint that I signed on
. I have not received promises,
rewards or concessions that might have influenced me to withdraw my complaint.
I voluntarily withdraw the request for an investigation and any consent that I may
have granted for release of information.
I, the undersigned, do not wish to proceed with the Discrimination Complaint that I
(Please check all statements that apply and sign and date below.)
1. The issues I raised in my complaint are now resolved.
2. I no longer believe that I have a discrimination complaint.
3. I am currently receiving the benefits I am entitled to receive.
4. I understand that the changes in current laws prohibit me from
RETURN this form to:
Department of Human Services/Personnel Office
Civil Rights Compliance Staff
P. O. Box 339
Honolulu, Hawaii 96809-0339
SEND questions to:
NOTE: Please be advised that no one may intimidate, threaten, coerce or
engage in other discriminatory conduct against another individual who takes
action or participates in an action to secure his or her rights protected by civil
rights laws. Anyone who claims retaliation or intimidation for having filed an
alleged discrimination complaint or for having served as a witness in an
investigation may file a complaint with the appropriate Department of Human
Services’ office and/or Federal and State Agencies, which will investigate the
DHS 6007 (Rev. 06/2014)