Complaint Intake Form

First Name

Middle Initial

Last Name

Street/Mailing Address

Apt. or Unit #

City

State

Zip Code

Email

Phone Number

Is it okay to leave a voicemail message?

Date of Birth

Gender

Do You Have a Disability?

What is Your Race?

Ethnicity

Number of Adults in the Home

Number of Children (under 18) in the Home

What is Your Marital Status?

Are You a Veteran or Active Military?

What is Your National Origin (Country of Origin or Ancestry)?

Date(s) of Harm

Harmful Action(s)

Name & Title of Person(s) Responsible

Please describe how you believe you were discriminated against.