ATTORNEY GENERAL ANDREW M. CUOMO STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL CIVIL RIGHTS BUREAU 120 BROADWAY, 3rd FLOOR NEW YORK, NEW YORK 10271-0332 HOTLINE: (800) 771-7755 TEL: (212) 416-8250 FAX: (212) 416-8074 WEB SITE: http://www.oag.state.ny.us
CIVIL RIGHTS COMPLAINT FORM
1. PLEASE NOTE: The Civil Rights Bureau enforces laws protecting New Yorkers from discrimination on the basis of race, creed, color, national origin, sex, religion, age, marital status, sexual orientation, predisposing genetic characteristics, military status or disability. The Bureau does not investigate or litigate cases on behalf of individuals, or against state agencies. The Bureau primarily seeks to change patterns, practices and policies of discrimination that affect groups of people. If you believe that you are a victim of unlawful discrimination, and that others may have had a similar experience, please complete this form and mail it to our office at the address above, or fax it to (212) 416-8074. Or, if you wish to speak to someone about your complaint, call our office at (212) 416-8250. 2. If you choose to enclose any additional documents concerning your complaint, please make sure you enclose copies (not originals) of those documents. 3. The Attorney General is not your private attorney and this complaint form is not a lawsuit. If you have any questions about your legal rights or responsibilities, you should contact a private attorney. PERSON FILING COMPLAINT: Your Name ____________________________________________________________________ Street Address__________________________________________________________________ City/State/Zip __________________________________________________________________ Phone ________________________________________________________________________ WHO DO YOU BELIEVE DISCRIMINATED AGAINST YOU? Name of Person or Entity_________________________________________________________ Street Address__________________________________________________________________ City/State/Zip __________________________________________________________________ Phone ________________________________________________________________________ MY COMPLAINT IS RELATED TO:
9 9 9 9
Employment 9 Housing 9 Education 9 Other _________________________
Place of Business Credit/Lending Health/Reproductive Rights
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I BELIEVE I WAS DISCRIMINATED AGAINST BECAUSE OF MY:
9 9 9 9 9 9 9 9
Race 9 Color 9 Sex 9 Religion 9 National Origin 9 Marital Status 9 Familial Status 9 Other _________________________
Creed Disability Age Military Status Sexual Orientation Genetic Predisposition Ex-Offender Status
When did the discrimination happen? ____________________________________________ Where did the discrimination happen? ___________________________________________ Please describe the discriminatory treatment you experienced (attach additional pages if needed and include important dates or the period of time in which the discrimination occurred): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ -2-
Were there any witnesses to the discrimination?
9 Yes
9 No
9 Don’t Know
IF YES, please provide their names, addresses and/or telephone numbers, or feel free to provide them with our address, website and/or phone number so that they may contact us directly. ______________________________________________________________________________ ______________________________________________________________________________
Do you know if anyone else has also experienced the discriminatory treatment you just described? 9 Yes 9 No 9 Don’t Know IF YES, please provide their names, addresses and/or telephone numbers, or feel free to provide them with our address, website and/or phone number so that they may contact us directly. ______________________________________________________________________________ ______________________________________________________________________________
Have you also filed a complaint about the discrimination with any of the following agencies? New York State Division of Human Rights 9 Yes 9 No New York City Commission on Human Rights 9 Yes 9 No U.S. Equal Employment Opportunity Commission 9 Yes 9 No U.S. Department of Housing and Urban Development 9 Yes 9 No Other:___________________________________________________________ Are you represented by a private attorney? If YES, please provide his/her name and telephone number. ______________________________________________________________________________ Have you already filed a complaint in court?
9 Yes 9 No 9 Yes 9 No
If YES, please indicate which court it was filed in and the case name. ______________________________________________________________________________
(please continue on the following page.....)
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READ THE FOLLOWING BEFORE SIGNING BELOW: I understand that, by submitting this document, I am informing the Office of the Attorney General (“OAG”) of my complaint, and the OAG may decide whether to begin an investigation based on my complaint. I also understand that the Attorney General is not my private attorney, but represents the public to enforce laws designed to protect the public from patterns and practices of discrimination or discriminatory policies. This complaint is not the equivalent of filing a lawsuit or a complaint with any other government agency. For example, if I decide to file a complaint with the New York State Division of Human Rights or the Equal Employment Opportunity Commission, I understand that I must do that separately. I understand that filing this complaint with the OAG has no effect on any deadlines or statute of limitations that might apply to my claims. If I have any questions concerning my legal rights or responsibilities, I should contact a private attorney. The above complaint is true and accurate to the best of my knowledge. I also understand that any false statement made in this complaint is punishable as a Class A Misdemeanor under Section 175.30 and/or Section 210.45 of the Penal Law. Signature: ___________________________________________ Date:____________________ Send your signed complaint form to: State of New York Office of the Attorney General Civil Rights Bureau 120 Broadway, 3rd Floor New York, NY 10271-0332
If complaint form completed by OAG staff, please print name:__________________________
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