Complaint Form | NAACP Riverside Branch Chapter 1059

NAACP Member *

Yes
NO

First Name *

Address, City, St, Zip

Email *

Phone

Cell Phone

Race

Sex:

Male
Female

Age

Do you currently have an attorney?

Yes
No

Employment Discrimination

Consumer Fraud

Leasing: auto or equipment (excessive fees, late fees, hidden fees)
Credit card issues (excessive fees, late fees, hidden fees)
Mortgage issues (excessive fees, late fees, hidden fees, foreclosures)
Insurance issues (excessive fees, late fees, hidden fees)
Predatory lending (discrimination against minorities in lending)
Deceptive billing practices (e.g. cell and telephone charges)
False and misleading advertising
Defective products

Public Accommodations Discrimination

Denial or improper treatment (restaurants, hotels, stores, hair cutting, etc.)
Racial profiling
Housing discrimination

Criminal Law

Racial profiling
Unlawful arrest (battery, unreasonable use of force)

Attorney's Name *

Attorney's Telephone # *

Attorney's Address *

City, State, Zip *

Has a lawsuit been filed?

Yes
No

Have you filed a complaint with the EEOC?

Yes
No

Have you filed a complaint with Fair Employment & Housing?

Yes
No

Have you filed submitted a complaint or grievance with the police department, your supervisor, or anyone in an administrative role?

Yes
No

Description:

By whom were you discriminated? - Include name(s), race, and gender of each:

How were you discriminated against? - Include name(s), race, and gender of each:

Address #1 City. State, Postal Code

Address #2, City, State, Postal Code

Witness #1 Name, address, & Phone number

Available to take a statement?

Yes
No

What was the effect or impact of the discriminating behavior on you?

To date, what actions have you taken so far?

To date, what actions have you taken so far? (copy)

Have you filed a complaint with or notified any other organization or individual regarding this matter?

Yes
No

Please include name, address, and phone number

What actions, if any, were taken in response to the complaint or notice of concern?

Who took these actions?

When were these actions taken?

What would you like the NAACP to do for you regarding the discrimination?

Release of Liability: *

I affirm that the statements I have made above are accurate and true to the best of my knowledge and belief. I hereby request the assistance of the NAACP in seeking remedy of the situation described above. I hereby authorize the officers and executive committee of the NAACP to have access to information and documents which are relevant to my claim of discrimination described above.
I understand that once a referral to a volunteer, community agency or private attorney has been made, the NAACP WILL NOT BE RESPONSIBLE for handling this matter. In fact, I further understand that by signing this document, I am agreeing to HOLD THE NAACP harmless of any and all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.

Name *

First

Last

Non-Retaliation Requirements:

NON-RETALIATION REQUIREMENTS Section 704 (a) of the Civil Rights Act of 1964, (as amended), Section 4 (d) of the Age Discrimination in Employment Act of 1967, (as amended), and various other civil rights laws make it an unlawful employment practice for an employer; employment agency; or labor organization: to discriminate against employees, applicants for employment, member or applicant for membership, because the employee, member or applicant has opposed an unlawful employment practice, made a charge, testified, assisted, or participated in any manner in an investigation, proceeding or hearing. COMPLETION OF THIS FORM 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 forward this information with sustaining documents to: NSDC NAACP INFO@NSDCNAACP.ORG