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2. Your Name
4. Your Address
6. Your City
7. Your State
8. Your Zip Code
10. Your Phone Number
11. (Work/Other)
15. Person discriminated against (if someone other than yourself):
17. Name
19. Address
21. City
22. State
23. Zip Code
27. Agency and Department or program you allege engaged in discrimination:
29. Basis for alleged discrimination (check all that apply):

    1. Race/Color
    2. National Origin
    3. Sex

    1. Religion
    2. Age

    1. Disability
    2. Family Status
31. What date did the alleged discrimination take place?
    What date did the alleged discrimination take place?
33. In your own words, describe the alleged discrimination as clearly as possible, why you believe it happened, and how you were discriminated against. Tell us who was involved, and who you believe was responsible. Be sure to include how other persons were treated differently from you. Please use additional sheets if necessary and attach a copy of written materials that you think supports your complaint.
35. Please list all witnesses with contact information who may help us investigate your claim.
37. Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?

    1. Yes
    2. No
39. If yes, check all that apply:

    1. Federal Agency
    2. Federal Court
    3. State Agency

    1. State Court
    2. Local Agency
41. Please provide information about a contact person at the agency/court where the complaint was filed:
43. Name
45. Address
47. City
48. State
49. Zip Code
51. Phone Number
55. We cannot accept a complaint if it has not been signed. Please sign and date this form on the lines shown below:
57. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
59. Electronic Signature*
61. Date:*
    Date:
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field