Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement 2007 Page 2
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46. STATEMENT: What did the respondent do? List each action you believe was discriminatory. (For
example: I was denied access or service, charged a higher than regular rate, etc.) Then, say why
you believe you were treated differently because of the basis you listed above.
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7. DATES: (month/day/year)
When did the above action(s) first happen?
On what date did it last happen?
8. By my signature below, I acknowledge that I have read the complaint; that to the best of my
knowledge, information and belief, the complaint is true and correct, and that the complaint is not
being used for any improper purpose, such as to harass the party against whom the complaint is
filed.
Signature of Complainant or Authorized Representative
Date Signed (month, day, year)
Sworn To Before Me On (month, day, year)
My Commission Expires (month, day, year)
Notary Public Signature (affix seal)
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