Discrimination Complaint Form | Cattaraugus County Website

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Complainant

Complainant's First Name

Complainant's Last Name

Complainant's Street Address

Complainant's City/Town

Complainant's State/Province

Complainant's ZIP/Postal Code

Complainant's Email Address

Confirm Complainant's Email Address

Complainant's Home Telephone

Complainant's Business Telephone

Person Discriminated Against
(if other than the complainant)

Person Discriminated Against First Name

Person Discriminated Against Last Name

Person Discriminated Against Street Address

Person Discriminated Against City/Town

Person Discriminated Against State/Province

Person Discriminated Against ZIP/Postal Code

Person Discriminated Against Home Telephone

Person Discriminated Against Business Telephone

Government or Organization or Institution which you believe has discriminated:

Name

State

Postal Code

Telephone Number

When did the discrimination occur?

Describe the Acts of discrimination

Describe the acts of discrimination providing the name( s) where possible of the individuals who discriminated

Have efforts been made to resolve this complaint?

Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization, or institution?

Yes

If yes: What is the status of the grievance?

Has the complaint been filed with another bureau, agency or court?

Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?

Yes

Agency or Court Name

Contact Person

Street Address

City/Town

State/Province

ZIP/Postal Code

File with another Agency or Court

Do you intend to file with another agency or court?

Yes

Agency or Court Name

Street Address

City/Town

State/Province

ZIP/Postal Code

Enter your full name

Please enter your *First Name, *Middle Name and *Last Name to confirm that you've filled out this form.