Complaint of Discrimination

Completing this form does not constitute filing an official complaint with a legal authority. At this time, the NAACP is only seeking information to assist you concerning this complaint. Please fill out this form and send only COPIES of supporting documents or documentary evidence. Please do not include any originals. Mail, email, deliver or fax documentation to: Greater New Haven Branch of the NAACP 545 Whalley Avenue, New Haven, CT 06511 | Tel: 203-389-7275 Fax: 203-389-7626 Email: GNHlegal@gmail.com

First Name

Last Name

Address 1

City

Zip / Post Code

Phone

Who discriminated against you? Give names and address of the indiviaul9s), organizations, company, etc.

Name

Address 1

City

Zip / Post Code

Other Parties (if any):

Have you ever filed a complaint with any governmental agency(ies)? If so, which one(S)

Agency

Have you ever filed a grievance with your union?

Name of Local Representative

Have you retained an attorney regarding this case?

Name of Attorney/Firm

Address 1

City

The actual date or the most recent date on which this discrimination occurred

Our mission is to address discrimination in all of its forms. Our committee has been successful in addressing and mediating situations of discrimination and in providing a conduit between needs and resources. We are not attorneys. If an attorney is requested, the National Office of the NAACP recommends that we offer the names of three attorneys. The also recommend that our involvement with a case not to exceed 180 days or six months.

I fully understand the limitations outlined above (type your initials)

Please describe your complaint.

I AFFIRM THAT I HAVE SUBMITTED THE ABOVE CHARGE AND THAT IT IS TRUE TO THE BEST OF MY KNOWLEDGE, INFORMATION, AND BELIEF.

Electronic Signature

Date Signed

The NAACP uses member volunteers in all aspects of its operations. Financial support for its efforts depends primarily on its membership strength. We encourage you to support our efforts by becoming a member at $30 a year, which includes a monthly subscription to the Crisis magazine. Or you might want to make a contribution. However, be assured that membership is not required to receive our assistance. We will assist in rectifying problems of unfairness wherever and whenever possible and practical.

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Message from the President