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Complaint Form

  1. The following information is needed to assist in processing your complaint:

  2. Complainant's Information

  3. Accessible Format Requirements

  4. Person discriminatied against (if someone other than complainant):

  5. Have you obtained the permission of the aggrieved party if you are filing on behalf of a third party?

  6. Which of the following best describes the reason you believe the discrimination took place?

  7. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? List all that apply:

  8. Please provide information about a contact person at the agency/court where the complaint was filed:

  9. Formulario para una querella. Nota: La siguiente información es necesaria para ayudarlo a procesar una querella A. Información del Denunciante:

  10. Formato de preferencia: (seleccione uno o más)

  11. Leave This Blank:

  12. This field is not part of the form submission.