NAACP Legal Redress Form

This is form is for filing a complaint based on race, color, religion,
origin, sex, age or handicapped status. Completing this form does
not constitute filing an official complaint with a legal authority. At
this time, the NAACP is only seeking information to assist you
concerning this complaint.

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

What was the discrimination because of?

If other, please describe.

Who discriminated against you?

Address of Discriminator

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Other discriminating parties

Have you ever filed a complaint with any governmental agency(ies)?

If so, which agency(ies)?

Have you ever filed a grievance with your union?

Name of Local and Representative:

Have you retained an attorney regarding this case?

Name of Attorney/Firm:

Attorney/Firm Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

The actual date or the most recent date on which this discrimination occurred:

MonthDayYear

Time of day in which this discrimination occurred

Please attach all supporting documents

Upload a File

Please state and describe your claim.

I AFFIRM THAT I HAVE SUBMITTED THE ABOVE CHARGE AND THAT IT IS TRUE TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.