NAACP Complaint of Discrimination Form 1-2021

Lexington-Fayette Unit NAACP - P.O. Box 13655 Lexington, KY 40508

Completing this form does not constitute filing an official complaint with a legal authority. The NAACP is only seeking information to assist you concerning this complaint. Please NOTE that the NAACP Lexington-Fayette Branch does NOT Provide and CANNOT Provide Legal Representation or Advice. We refer you to the attached page for attorney resources and for the filing of formal complaints.
Name
Member/Unit#
Street Address
City
State
Zip Code
Phone
Phone Number
Please enter a valid phone number.
Email
example@example.com
Was discrimination because of?

Race or ColorSexNational OriginReligionAgeHandicapped StatusOther
The actual date or the most recent date on which this discrimination occurred:
Time
Month
Day
Year
Who discriminated against you? Give name and address of the discriminating party.
Name
Street Address
City
State
Zip Code
Other Parties:
+Have you filed a complaint with any governmental agencies?

YesNo
If YES, which ones?
+Have you filed an internal grievance with the discriminating party?

YesNo
+ Have you retained an attorney regarding this case?

YesNo
If YES, name phone number and address of attorney:
Describe in detail the discrimination you experienced:
I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief:
Signature

Clear
Date

MonthDayYear
Date
Please upload any supporting documentation that will assist with your case

Cancelof
Should be Empty: