Complaint of Discrimination under Iowa Code Chapter216
"Iowa Civil Rights Act of 1965"
Iowa Civil Rights Commission 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?
City: State: Zip Code:
3. Telephone Number: () -
4. What is your date of birth? Sex:
Race: National Origin(ancestry):
SS#: - - (voluntary)
5. On what BASIS(ES)do you feel you have been discriminated against? (Please check)
Age Physical Disability Color
Race Creed Religion
Marital Status Sex Mental Disability
National Origin Pregnancy Retaliation*
* Because I filed prior complaint or opposed a discriminatory practice
6. Please check the AREA in which the discrimination occurred.
Credit Education
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:
County: Adair Adams Allamakee Appanoose Audubon Benton Black Hawk Boone Bremer Buchanan Buena Vista Butler Calhoun Carroll Cass Cedar Cerro Gordo Cherokee Chickasaw Clarke Clay Clayton Clinton Crawford Dallas Davis Decatur Delaware Des Moines Dickinson Dubuque Emmet Fayette Floyd Franklin Fremont Greene Grundy Guthrie Hamilton Hancock Hardin Harrison Henry Howard Humboldt Ida Iowa Jackson Jasper Jefferson Johnson Jones Keokuk Kossuth Lee Linn Louisa Lucas Lyon Madison Mahaska Marion Marshall Mills Mitchell Monona Monroe Montgomery Muscatine O'Brien Osceola Page Palo Alto Plymouth Pocahontas Polk Pottawattamie Poweshiek Ringgold Sac Scott Shelby Sioux Story Tama Taylor Union Van Buren Wapello Warren Washington Wayne Webster Winnebago Winneshiek Woodbury Worth Wright 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 against you?
Name:
Position/Title:
14. If you are claiming harassment, who harassed you?
15. What is the last date that something discriminatory happened to you?
What happened on that date?
Please fill in the particulars of your complaint below.
Be sure to state why you feel you were discriminated against.
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.
X _____________________________________________ Date __________________
Signature of Complainant
Verification without notary authorized by Iowa Code section 622.1; 28 U.S.C. section 1746
Intaker Name _____________________ Phone ________________ (direct extension)
Disability Code _________
Contact Information
Authorization Release Form