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Discrimination Complaint Form
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Complainant
Complainant's First Name
Complainant's First Name
Complainant's Last Name
Complainant's Last Name
Complainant's Address
Complainant's Street Address
Complainant's City/Town
Complainant's State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Complainant's ZIP/Postal Code
Complainant's Address
Complainant's Email Address
Complainant's Email Address
Confirm Complainant's Email Address
Complainant's Home Telephone
Complainant's Home Telephone
Complainant's Business Telephone
Complainant's Business Telephone
Person Discriminated Against
(if other than the complainant)
Person Discriminated Against First Name
First Name of Person Descriminated Against
Person Discriminated Against Last Name
Person Discriminated Against Last Name
Person Discriminated Against Address
Person Discriminated Against Street Address
Person Discriminated Against City/Town
Person Discriminated Against State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Person Discriminated Against ZIP/Postal Code
Person Discriminated Against Address
Person Discriminated Against Home Telephone
Person Discriminated Against Home Telephone
Person Discriminated Against Business Telephone
Person Discriminated Against Business Telephone
Government or Organization or Institution which you believe has discriminated:
Name
State
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
No
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
No
Agency or Court Name
Contact Person
Address
Street Address
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
File with another Agency or Court
Do you intend to file with another agency or court?
Yes
No
Agency or Court Name
Address
Street Address
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.