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2. The following information is needed to assist in processing your complaint:
4. Complainant's Information
6. Name
7. Email Address
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Work Phone
18. Accessible Format Requirements

    1. Audio Tape
    2. Large Print
    3. TDD
20. Person discriminatied against (if someone other than complainant):
22. Name
23. Email Address
25. Address
27. City
28. State
29. Zip Code
31. Phone Number
32. Work Phone
34. Relationship to the person for whom you are complaining:
36. Please explain why you have filed for a third party:
38. Have you obtained the permission of the aggrieved party if you are filing on behalf of a third party?

    1. Yes
    2. No
40. Which of the following best describes the reason you believe the discrimination took place?

    1. Color
    2. National Origin
    3. Race
    4. Other
42. Describe other reason:
44. On what dates did the alleged discrimination take place?
    On what dates did the alleged discrimination take place? Start Date

    —

    On what dates did the alleged discrimination take place? End Date
46. Please describe the alleged discrimination. Explain what happened and whom you believe was responsible. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.
48. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? List all that apply:

    1. Federal Agency
    2. Federal Court
    3. Local Agency
    4. State Agency
    5. State Court
50. Please provide information about a contact person at the agency/court where the complaint was filed:
52. Name
53. Title
55. Address
57. City
58. State
59. Zip Code
61. Phone Number
62. Email Address
64. You may attach any written materials or other information that you think is relevant to your complaint.
66. Formulario para una querella. Nota: La siguiente información es necesaria para ayudarlo a procesar una querella A. Información del Denunciante:
68. Nombre
69. Correo electronico
71. Dirección
73. Cuidad
74. Estado
75. Código Posta
77. Número de teléfono
78. Trabajo Número de teléfono
80. Formato de preferencia: (seleccione uno o más)

    1. Audio cinta
    2. Letra de imprenta grande
    3. TDD (capacidad auditiva)
81. Parentesco con el/la denunciante:
83. Por favor explique por qué se está presentado esta querella para una tercera persona?
Leave This Blank:


85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

* indicates a required field