Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please 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
State
Zip Code
Program Type
*
Program Type
Case Number
*
Case Number
Phone Number
*
Phone Number
Format: (000) 000-0000.
I believe I have been discriminated against on the basis of:
National Origin Color Race Ancestry Ethnic Group Age
*
National Origin
Color
Race
Ancestry
Ethnic Group
Age
Sex
Gender Identity
Gender Expression
Sexual Orientation
Marital Status
Domestic Partnership
Medical Condition
Genetic Information
Religion
Political Affiliation
Disability
Any Other Applicable Basis
Explanation
*
Rows
Name Of Person Who Discriminated
Title
Date Of Occurrence
Place Of Occurrence Agency
Event 1
Event 2
Event 3
Describe in your own words what action(s) have happened to lead you to believe you have been discriminated against.
*
Describe in your own words what action(s) have happened to lead you to believe you have been discriminated against.
Indicate what resolution you are seeking.
*
Indicate what resolution you are seeking.
I understand the above information is true and complete to the best of my knowledge and belief.
I do not give my consent for the release of my name or other personally identifying information. I understand that this complaint may not be investigated as a result of my refusal to give my consent for the release of information.
I understand the above information is true and complete to the best of my knowledge and belief.
*
By signing this complaint, I am authorizing the CDSS Civil Rights Bureau (CRB) to reveal my identity and other personal information to persons at the organization or institution under investigation and to other Federal and State agencies in accordance with applicable federal and state laws and regulations. I hereby authorize CRB to receive material and information including, but not limited to applications, case files, personal records, and medical records. The material and information shall be used for authorized civil rights compliance and enforcement activities. I understand that I am not required to authorize this release and I do so voluntarily.
Signature
*
Submit
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