Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement 2007 (Page 3 of 4) in pdf

Discrimination Complaint Instructions--What Is Covered and How to File

If you believe you have been discriminated against in violation of the Public Accommodation & Amusement

Act, you may file a complaint with DWD’s Equal Rights Division. Your complaint must be filed within 300 days

of the action that you believe was discriminatory.

To accept your case, the Division must have certain information. Make sure you carefully follow the

instructions outlined below. The numbers on these instructions match the numbered sections on the front of

this form.

1. Complainant: You must write your legal name, address and telephone number.

2. Respondent: You must provide the complete name, address and telephone number of the business or

labor organization that the charge is being filed against. Generally, the respondent should be the business

or company name. If there is more than one respondent, list each separately.

3. Referrals: The City of Madison Equal Opportunities Commission (MEOC) administers an ordinance similar

to state law. The Equal Rights Division will handle your complaint if it is initially filed with us, but we will also

refer your complaint to MEOC if the public accommodation or amusement is located within Madison’s city

limits.

4. County: You must write the name of the county in which the discriminatory action occurred.

5. Basis: You must give a basis for your complaint. The Wisconsin Public Accommodation or Amusement Act

prohibits discrimination in the provision of goods and services on the following bases:

Race

Ancestry

Sex

Color

National Origin

Disability

Creed

Age (18+) in Lodging

Sexual Orientation

6. Statement: What was done? You should list each action you feel was discriminatory. When describing a

Respondent’s action in this section, the individual who took the action should be identified, if possible.

Then, tell us why you believe this action was taken because of the basis you listed.

7. Dates Action Occurred: Give us the first and last dates you believe discrimination occurred.

8. Your Signature: Do not sign the complaint until you are in the presence of a Notary Public who can notarize

your signature. Be sure the Notary uses a stamp or seal on the form. Make sure you or your representative

signs the form.

Mail your Completed and Notarized complaint to one of the following offices:

State of Wisconsin

Department of Workforce Development

Equal Rights Division

201 E WASHINGTON AVE, ROOM A300

819 N 6TH ST

PO BOX 8928

ROOM 255

MADISON WI 53708

MILWAUKEE WI 53203

Telephone: (608) 266-6860

Telephone: (414) 227-4384

FAX:

(608) 267-4592

FAX:

(414) 227-4084

TTY:

(608) 264-8752

TTY:

(414) 227-4081

Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement 2007 Page 3

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