Form Erd-4206a - Discrimination Complaint Fair Employment

IMPORTANT!!

PLEASE READ ALL INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].

State of Wisconsin

ERD Case #

Department of Workforce Development

Discrimination Complaint

Equal Rights Division

Fair Employment

TYPE OR PRINT IN BLACK INK

1. Your name, street address, city, state, ZIP code:

2. Respondent Name (Business name or labor organization

you believe discriminated against you. Include street

address, state and ZIP code.) If there is more than one

respondent, list each separately.

Your Phone Number (include area codes):

Home (

)

Work

(

)

Respondent Phone Number

(include area code):

(

)

3. Your complaint may be filed with another

agency unless you write “ no” here. See

4. County where employment is located:

#3 on reverse side for more details.

__________

Fair Employment

Other (which law?)

5. What law do you believe was violated?

6. BASIS: You must list a basis for your complaint. (For example: “ sex-female,” “ race-African American,”

“ handicap-visual impairment,” “ age-58,” etc.)

What is the basis for your complaint? ............................................................................................................................

7. STATEMENT: What did the respondent do?

List each action you believe was discriminatory. (For example: I was terminated, not hired, disciplined more harshly,

retaliated against, etc.) Then, say why you believe you were treated differently because of the basis you listed above.

..............................................................................................................................................................................................

8. DATES:

When did the above action(s) first happen? (mo/day/yr) ...............................................................................................

On what date did it last happen? (mo/day/yr) ................................................................................................................

For Office Use

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

ERD-4206A (R. 04/97)