Civil Rights Complaint Form Page 2
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2d. Sex
e. Age
f. Disability
g. Religion
h. Medical Condition
i. Marital Status
j. Sexual Orientation
7.
What date did the alleged discrimination take place?
8.
In your own words, describe the alleged discrimination. Explain what happened and whom
you believe was responsible. Please use the back of this form if additional space is required.
9.
Have you filed this complaint with any other federal, state, or local agency; or with any
federal or state court? Yes:
No:
If yes, check each box that applies:
Federal agency
Federal court
State agency
State court
Local agency
10.
Please provide information about a contact person at the agency/court where the complaint
was filed.
Name:
Address:
City:
State:
Zip Code:
11. Please sign below. You may attach any written materials or other information that you think is
relevant to your complaint.
Complainant’s Signature
Date
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