IOWA CIVIL RIGHTS COMMISSION COMPLAINT FORM

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


(AGENCY USE ONLY)

ICRC CP# ___________________________________

Local Commission # ________________________________

Equal Employment Opportunity Commission # _____________________________


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: 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?

City: State:     Zip Code:

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?

Name:

Position/Title:


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 _________

 

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