Discrimination under Iowa Code Chapter216
"Iowa Civil Rights Act of 1965"
Grimes State Office Building
400 East 14th Street
Des Moines, Iowa 50319-1004
NOTE: PLEASE TYPE OR PRINT (In Ink Only)
1. What is your legal name?
2. What is your street address?
State: Zip Code:
3. Telephone Number: () -
4. What is your date of birth?
Race: National Origin(ancestry):
SS#: - -
5. On what BASIS(ES)do you feel you have been
discriminated against? (Please check)
Race Creed Religion
Status Sex Mental
Origin Pregnancy Retaliation*
* Because I filed prior complaint or opposed
a discriminatory practice
6. Please check the AREA
in which the discrimination occurred.
Employment Public Accommodations
7. What is the FULL LEGAL NAME of the
business or company that discriminated against you?
What is that company's mailing address?
City: State: IOWA* Zip Code:
Telephone Number: () -
(*It must be located in Iowa; for
employment cases, this is where you worked)
8. What does that business/company do?
9. If the company named in # 7 is owned by
another company, what is the FULL LEGAL NAME of the Owner Company? (Parent or
Corporate Office of Company listed in #7)
What is that company's street address?
Telephone Number: () -
10. Give approximate total number of full
& part-time employees at ALL employer locations (VERY IMPORTANT):
4-14 15-19 20-100 101-200 201-500 500+
11. Have you filed this complaint with any
other Federal, State, or Local Anti-Discrimination Agency?Yes No
If yes, what agency?
On what date did you file?
12. If this
complaint can be cross-filed with the Equal Employment Opportunity Commission,
the Iowa Civil Rights Commission will cross-file, unless you indicate in
writing: "Don't cross-file."
13. Identify the person at the company who discriminated
14. If you are claiming harassment, who harassed
15. What is the last date that something
discriminatory happened to you?
What happened on that date?
Please fill in the particulars of your
Be sure to state why you feel you were
I certify under
penalty of perjury and pursuant to the laws of the State of Iowa and the laws
of the United States of America that the preceding charge is true and correct.
_____________________________________________ Date __________________
Signature of Complainant
Verification without notary
authorized by Iowa Code section 622.1; 28 U.S.C. section 1746
________________ (direct extension)
Disability Code _________
Authorization Release Form