Civil Rights Complaint Form civilrights@attorneygeneral.gov Civil Rights Enforcement Section th 14 Floor, Strawberry Square Harrisburg, PA 17120 717-787-0822 www.attorneygeneral.gov PLEASE NOTE: The Attorney General handles civil rights cases involving a pattern and practice of activity, matters involving a substantial portion of the population or an issue of public importance. YOU MAY STILL BE REQUIRED TO FILE A COMPLAINT WITH THE PENNSYLVANIA HUMAN RELATIONS COMMISSION (PHRC) TO PRESERVE YOUR INDIVIDUAL RIGHTS IN YOUR CASE. BY LAW, YOU MUST FILE A COMPLAINT WITH PHRC WITHIN 180 DAYS OF THE ACT OF ALLEGED DISCRIMINATION. Required fields are marked with an asterisk* Your information: Age Group: Are you a veteran? Are you on active duty? Yes Yes Name* No No Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. City* State* Zip Code* County* Daytime Phone Number* ( ) Home Phone Number* ( ) Email Address If completing this form on behalf of someone else, please complete the following information: Age Group: Are they a veteran? Are they on active duty? Yes Yes No No Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. Name* City* State* Zip Code* County* Daytime Phone Number ( ) Home Phone Number ( ) Email Address American LegalNet, Inc. www.FormsWorkFlow.com Who is the complaint against? Name of entity or person* Phone Number: ( Mailing Address ) City State Zip Code County Type of Business Number of Employees Who Work at the Business Named Above: Legal Representation: Check the applicable boxes on why you feel you were discriminated against (treated differently). Gender Religious Creed National Origin Marital Status Family Relations (Children Under 18) Disability - Identify your disability: Age - Indicate Date of Birth: Other: If you believe you were treated differently for a reason which is not listed, explain what you believe to be the reason: Race Ancestry Retaliation GED (General Equivalency Diploma) If Employment related, who in management have you informed of your complaint? Do you know of any other individuals who have been treated the same or received similar treatment? Yes No What action was taken? What happened to these individuals? Do you have any witnesses to verify or confirm your complaint? Yes No Provide the date(s) of incident(s) Please explain if you have suffered any monetary loss or loss of benefits: Have you filed a complaint about this matter with any other agency? Yes No If yes, please specify the agency and the date you filed, to the best of your recollection: Have you filed a court action in this matter? Yes No If yes, please specify in what court and the date you filed, to the best of your recollection: American LegalNet, Inc. www.FormsWorkFlow.com If you are represented by an attorney, please provide your attorney's name, address and telephone number: What do you want to see happen as a result of your complaint? Complaint Information:* Please explain your complaint including the details such as date, time and location. Describe the events in the order in which they happened. If your complaint is based on race, include the race of all persons mentioned (including yourself). If it is a gender complaint, supply the general of all persons mentioned, etc. PLEASE READ CAREFULLY THE ATTORNEY GENERAL CANNOT ACT AS YOUR PRIVATE ATTORNEY As a law enforcement agency, the primary function of the Attorney General is to represent the public at large by enforcing laws prohibiting acts of discrimination where there is a pattern or practice of unlawful activity. Your complaint does remain on file with our office and the information contained in it may be used to establish future violations of Pennsylvania law or other issues of general public importance I hereby verify that the information provided is true and correct to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. � 4904, relating to unsworn falsification to authorities. YOUR SIGNATURE DATE American LegalNet, Inc. www.FormsWorkFlow.com