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Intake Form for Civil Rights Unit

"*" indicates required fields

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!
Full Name * Required
Current Address * Required
MM slash DD slash YYYY
Select all that apply.
Ethnicity - Hispanic/Latinx?
Select an option.
I authorize this office to contact other parties regarding my concerns. * Required
I authorize this office to send me emails of general interest. * Required
I authorize a follow-up call regarding my concerns. * Required
Type of Adverse Party
Address of Adverse Party
Select all that apply.
Have you filed a complaint with another agency or organization?
Are you represented by an attorney?
Are we authorized to contact your attorney?
Are you aware of other individuals who may have been subjected to the alleged discriminatory conduct?
By submitting the following form, you are agreeing that you understand that the North Carolina Department of Justice cannot provide individual legal advice or provide individual legal representation. * Required
You are also affirming, by filing this form, that all provided information is true and accurate to the best of your knowledge. Once you file this form, your submission will be reviewed by our staff. We will review the matter as soon as possible. Please be aware that if your matter related to an ongoing court matter, we are not able to intervene in the process. * Required