Intake Form for Civil Rights Unit

Please fill out the form below as completely as you can. Please note messages to or from this address may be public records.

SUBMITTING THIS FORM HAS NO EFFECT ON ANY STATUTE OF LIMITATIONS OR OTHER FILING REQUIREMENTS THAT MIGHT APPLY TO ANY CAUSE OF ACTION YOU MAY HAVE. FURTHER, BY SUBMITTING THIS FORM YOU HAVE NOT COMMENCED A LAWSUIT OR OTHER LEGAL PROCEEDING. THIS OFFICE HAS NOT INITIATED A SUIT OR PROCEEDING ON YOUR BEHALF. IF YOU BELIEVE YOUR CIVIL RIGHTS HAVE BEEN VIOLATED, AND INTEND TO BRING A LAWSUIT, YOU SHOULD ALSO CONTACT AN ATTORNEY.

Once you complete this form, we will contact you with more information on how we will proceed. Thank you!

Residential County *

Email

Primary Phone

Date of Birth

Race

Select all that apply.

National Origin

Sex/Gender

Select an option.

Religion/Creed

Disability

Do you have witness(es) who can corroborate your accounts? If so, please provide names and contact information.

If Department has permission to contact other individual's, please provide their name and contact information.

Adverse Party (person or company you have a dispute with)

Adverse Party - Phone Number

Adverse Party - Email

Type of Concern

Select all that apply.

Other type of Concern

Please describe the nature of your concern in detail, including the most recent date of harm.

Other Agencies Where Complaint Filed

Select an option.

Other Agency Where Complaint Filed

Attorney Name

Attorney Email

Attorney Phone

What resolution are you seeking?

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