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NAACP Fort Wayne/Allen County (IN)Branch#3049

P. O BOX 10856

Fort Wayne, IN 46854

Larry D. Gist, President

Theme “VICTORY IS OURS”

Email: 3049FWANAACP@GMAIL.COM

260-515-1140

Legal Redress

CONFIDENTIAL COMPLAINT FORM

DISCLAIMERS

The purpose of this form is to gather information for the Legal Redress Committee to consider when determining whether the NAACP Fort Wayne Indiana, branch may be able to assist you with your complaint of discrimination. Completing this form does not constitute an official complaint with a legal authority, such as filing a lawsuit or a complaint with a governmental agency. Nor does completing this form establish an attorney-client relationship between the NAACP Fort Wayne Indiana, branch, and the complainant.

CONTACT INFORMATION

Name: Click or tap here to enter text.

Address (City, State & Zip Code): Click or tap here to enter text.

Phone Number Type (Select type): Choose an item.

(Enter Phone Number)Click or tap here to enter text.

Email Address: Click or tap here to enter text.

BACKGROUND INFORMATION

  1. Are you a member of the NAACP? Choose an item.
    1. If YES, membership number: Click or tap here to enter text.           
  2. Are you currently represented by an attorney in this matter? Choose an item.  
  3. Has an attorney ever represented you in this matter? Choose an item.       
  4. If Yes, attorney’s name: Click or tap here to enter text.
  5. Attorney’s phone number: Click or tap here to enter text.     
  6. May we contact your attorney?          Choose an item.
  • Have you filed a complaint with any government agency? Choose an item.(Many filings are subject to strict time limitations.)
  • If Yes, agency name: Choose an item.         
  • Date: Click or tap here to enter text.
  • Contact person (if any): Click or tap here to enter text.        
  • Have you contacted any other nonprofit organization about your complaint? Choose an item.
  • If Yes, organization name:  Click or tap here to enter text.
  • DateClick or tap here to enter text.

COMPLAINT

  1. Did the discrimination complained of occur in Fort Wayne, Indiana? Choose an item.
  2. Location as to where it took place.           Click or tap here to enter text.
  3. What was the basis of the discrimination you experienced? (Check all that apply.)

☐ RACE              ☐ COLOR     ☐ NATIONAL ORIGIN         ☐ RELIGION

☐ AGE                                         ☐ HANDICAP                       ☐ MARTIAL STATUS

☐ FAMILIAL STATUS               ☐SEX                                    ☐ SEXUAL ORIENTATION

☐ GENDER IDENTITY OR EXPRESSION                  ☐ SOURCE OF INCOME

☐ PLACE OF RESIDENCE OR BUSINESS   

☐ MATRICULATION (STUDENT STATUS)               ☐ PERSONAL APPERANCE

☐ POLITICAL AFFILIATION                                        ☐ OTHER    

  • On what date(s) did this occur: Click or tap here to enter text.
  • Who discriminated against you? Click or tap here to enter text.
  • What is your relationship in this complaint? (e.g., employee, tenant, customer)

            Click or tap here to enter text.

  • Address: Click or tap here to enter text.
  • Phone number: Click or tap here to enter text.
  • Email address:Click or tap here to enter text.
  • May we contact this person or entity? Choose an item.
  • Were there any witnesses to these events?         Choose an item.
  1. If Yes, name:   Click or tap here to enter text.Phone numberClick or tap here to enter text.
  2. May we contact the individual? Choose an item.
  3. If Yes, name:Click or tap here to enter text. Phone number: Click or tap here to enter text.
    1. May we contact the individual?  Choose an item.
  4. If Yes, name: Click or tap here to enter text.Phone number: Click or tap here to enter text.
    1. May we contact the individual?  Choose an item.
  5. If Yes, name:   Click or tap here to enter text.Phone number: Click or tap here to enter text.
    1. May we contact the individual?  Choose an item.
  • Have you recorded or saved any evidence?       Choose an item.
  • If Yes, please list: Click or tap here to enter text.

(Documentary evidence may be attached to this complaint form. However, please do not include any originals.)

Please briefly describe the discrimination you encountered.Click or tap here to enter text.

(ATTACH ADDING PAGES IF NEEDED)         

I do hereby authorize representatives from the NAACP Legal Redress Committee to investigate and obtain information regarding this complaint on my behalf. Choose an item.

I affirm that I have reviewed this complaint form and that it is true to the best of my knowledge, information, and belief.

        Signature:Click or tap here to enter text.              Date:   Click or tap here to enter text.

Please mail by regular mail or email completed form to:

NAACP

P. O BOX 10856

Fort Wayne, IN 46854

Attn: Legal Redress Committee

Email: 3049FWANAACP@GMAIL.COM

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