Form Erd-10241 - Discrimination Complaint Public Accommodation Or Amusement 2007 Page 4
ADVERTISEMENT
1
2
3
4Equal Rights Complaint Process Information
For effective complaint handling, please complete and return the following information with your complaint.
Your Last Name
Your First Name
Your Middle Initial
Today’s Date
Your Social Security Number *
* Not mandatory - used only for internal identification, accessibility and
accuracy of records within the Equal Rights Division
Witnesses: Please include the names, home addresses and telephone numbers of persons who know what
happened to you or may have seen, heard or experienced treatment similar to yours. Witnesses are not
character references. They are people who have relevant information about your complaint and are willing to
cooperate in the investigation.
________________________________________________________________________________________
________________________________________________________________________________________
Availability: (Important! You must notify the Department if you change your address or phone number. If we
are unable to locate you, your complaint may be dismissed.)
What Days and times are you usually available to discuss your complaint?
________________________________________________________________________________________
________________________________________________________________________________________
Is there a telephone where we can reach you during the day?
Yes
No
If so, please provide the area code and number: (
)
In case we cannot reach you, please provide the name, address and phone number of a person who does not
reside with you but will always know where you live and how to reach you.
Name
Street Address
City
State
Zip Code
Telephone Number
(
)
Settlement Information
At this time, what would you accept to settle your complaint?
________________________________________________________________________________________
________________________________________________________________________________________
Complaint Information
Have you filed this charge with any
If so, name of agency?
Date Filed
other agency?
Yes
No
Statistical Information
Complainant Sex
Male
Female
Complainant Race (check appropriate box or boxes)
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Black or African American
Asian
White
Unknown
Complainant National Origin or Ethnic background (check one)
Hispanic or Latino
Arab, Afghani or Middle Eastern
Other
4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Erd Case - Discrimination Complaint Wisconsin Fair Employment Law. Equal Rights Complaint Process Information Sheet
Legal
Form Hhs-699 - Discrimination Complaint - Department Of Health And Human Services - Office For Civil Rights (ocr)
Business
Form 4506-a - Request For Public Inspection Or Copy (rev. August 2003) Of Exempt Or Political Organization Irs Form
Financial
Related Categories
Parent category: Legal