Please Note: The NAACP is unable to respond to cases in litigation. We regret any inconvenience.

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Name and Address of Complainant:

* First Name:

Last Name:

* Address:

* City:

State:

* Zip:

* Phone Day:

Phone Evening:

* E-Mail:

Name and Address of Respondent (party you are filing against):

* Name:

Company:

Address:

* City:

* State:

* Zip:

* Phone:

* E-Mail:

The discrimination was because of (please check appropriate reason(s)):

* Please Select:

* Have you filed a complaint with any governmental agencies?

If yes, please state which:

If yes, please provide contact info:

Name:

Address:

City:

State:

Zip:

Phone:

E-Mail:

* Factual Information about your complaint. Please include name(s) and date(s). Tell us as much as you can and why you believe your civil rights were violated.

* Requested Relief:

* Please list here any supportive documentation you can provide, and enclose same.

* Are you a present or past member of the NAACP?

If yes, please identify the branch and your membership expiration date:

* The provided information is true and accurate to the best of my knowledge, I have not knowingly made any false claims to the Monroe County NAACP. Click Yes to confirm.

Yes

* Date:

Complaint Form

Name and Address of Complainant:

Name and Address of Respondent (party you are filing against):

The discrimination was because of (please check appropriate reason(s)):

If yes, please provide contact info: