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2. Section 1. Contact Information
4. First Name*
5. Last Name*
7. Phone Number*
9. Email Address
11. Address
13. City
14. State
15. Zip Code
17. Section 2. Complainant Information
19. Are you filing this complaint on your own behalf?

    1. Yes
    2. No
21. If yes, skip to section 3.
23. If No, please provide the following contact information for the person discriminated against:
25. First Name
26. Last Name
28. Address
30. City
31. State
32. Zip Code
34. Email Address
36. Section 3. Incident Description
38. Date of the alleged discrimination
    Date of the alleged discrimination
40. Location of the alleged discrimination:
42. Explain as clearly as possible what happened and why you believe that you were discriminated against. Describe all of the persons, program and/or services involved.*
44. Section 4. Incident Information
46. Please list any and all witnesses’ names and phone numbers/contact information.
48. Have you discussed your complaint with a County employee?

    1. Yes
    2. No
50. If yes, provide name(s) and position(s)
52. Have you filed your complaint with a federal, state, or local agency; or with a federal or state court?

    1. Yes
    2. No
54. You may attach any written materials or other information you think is relevant to your complaint.

    Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

56. By inputting my name below, I affirm that the above is true to the best of my knowledge, information, and belief.
58. Name*
59. Date*
    Date
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

* indicates a required field