Iowa-Nebraska NAACP Complaint Form 1

***Please Note: Due to the limited capacity of our volunteer Legal Redress Committee we are experiencing an at least 3-month delay in processing complaints. If your concern is urgent you may complete the form so we can document your complaint, however you should also strongly consider contacting any of these other legal sources by clicking here. These organizations are staffed and can offer more immediate service.

OUR MISSION

The mission of the National Association for the Advancement of Colored People is to ensure the political, educational, social, and economic equality of rights of all persons and to eliminate race-based discrimination.

VISION STATEMENT

The vision of the National Association for the Advancement of Colored People is to ensure a society in which all individuals have equal rights without discrimination based on race.

PURPOSE OF COMPLAINT FORM

Please be advised that filing a complaint of discrimination with the NAACP is considered a request for support and does not gaurantee that the NAACP will represent you in any matter, legal or otherwise. The filing of a this form does not form an attorney-client relationship. The NAACP may not give legal advice to any persons or entity, but upon investigating a matter, may refer any person or entity seeking legal advice to attorneys who are available to receive such referrals.

REFERRAL STATEMENT

The Iowa-Nebraska NAACP State Area Conference of Branches will seek to refer complaints to the appropriate local unit or agency for processing. In some cases which merit state level involvement, the Iowa-Nebraska NAACP retains the option to process the complaint directly or in concert with a local unit/branch.

ADDITIONAL TIME-SENSITIVE INFORMATION:

If you believe that you have a discrimination claim, we strongly recommend that you also file a claim with the appropriate local, state or federal agency as soon as possible. Failure to do so may limit the opportunity to rectify the issue. Filing time limits can be as short as 90 to 300 days. Please find a list of some agencies here.

TODAY'S DATE*

MonthDayYear

First Name*

Last Name*

E-mail*

Home Phone Number*

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

Street Address*

Street Address Line 2

City*

State*

Zip Code*

Date of incident or situation*

MonthDayYear

Additional dates of incident or situation, please use full calendar dates

Are you a member of the NAACP*

YesNo

Which of the following NAACP branches/units is closest to you?*

Is this a complaint of discrimination?*

YesNo

What was the basis of the discrimination?*

Race, Culture or ColorOther

If you answered "other" above, please specify.

Who or what entity do you believe discriminated against you?*

Please provide the contact person(s), title, complete address, email and phone number for the discriminating party.*

Location of the incIdent(s): List complete addresses.*

Please describe what happened being as detailed as possible.*

What effect has the incident(s) had on you?*

Do you have an attorney?*

YesNo

Have you filed a lawsuit or taken legal action?*

YesNo

If you have an attorney, what is the name, phone, email and address of your attorney.

If you have filed, what is the outcome or current status of any lawsuit or legal action taken?

Have you filed complaint with another agency?*

YesNo

If so, please indicate which of the following agencies to which you have filed a complaint.

The discriminating entity's leadership or complaint processEqual Employment Opportunity CommissionDepartment of Justice (DOJ)Department of Human RightsDepartment of Civil RightsOther

If so, what is the outcome or current status of claims filed with any agency above?

Please upload any documentation or files relevant to your complaint.

Upload a File

What is your desired outcome? Please be as detailed as possible.*

RELEASE OF LIABILITY

I affirm that the statements that I have made above are accurate to the best of my knowledge and belief. I hereby request the assistance of the of the Iowa-Nebraska State Area Conference of Branches and/or its appropriate units in seeking a remedy to the situation described above. I hereby authorize the officials of the NAACP to have access to information and documents which are relevant to my claim of discrimination described above.

I understand that by signing this document in the space below, I hold the NAACP harmless for any and all damages, legal claims or lawsuit arising from involvement.

I have read this form in its entirety and understand that the NAACP is experiencing a delay is processing complaints.*

I do affirm and understand.

Please sign this document by typing your full name*

Verify your signature by providing the last 4 digits of your social security number*

Thank you!

NAACP DISCRIMINATION COMPLAINT FORM