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 Color Sex National Origin Religion Age Handicapped Status Other

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?

Yes No

If YES, which ones?

+Have you filed an internal grievance with the discriminating party?

Yes No

+ Have you retained an attorney regarding this case?

Yes No

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

Please upload any supporting documentation that will assist with your case

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