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2. Please complete this form to the best of your ability. Contact Deputy City Administrator/Finance Director David Goldman if you need translation or other assistance.

4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Primary Phone Number*
14. Alternate Phone Number
16. Tell us when is the best time of day to contact you:*
20. Basis of Complaint
22. Select all that apply to your complaint*

    1. Race

    1. Color

    1. National Origin (includes language access)
24. Date of alleged incident*
    Date of alleged incident
28. Who discriminated against you?
30. Name of Individual*
31. Name of Organization
33. Address
35. City
36. State
37. Zip Code
39. Phone Number
43. Details of the Alleged Incident*

    Explain what happened, why you believe it happened, and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. If you have any other information about what happened, please attach supporting documentation to the form. 

    
    

45. What remedy are you seeking for the alleged discrimination?*

    Note: This process will not result in the payment of punitive damages or financial compensation. 

47. List any other persons that we should contact for additional information in support of your complaint.

    List their names, phone numbers, address, and email addresses below. 

51. List any past complaint, grievance, or lawsuit with any other agency or court.

53. Who
54. When
56. Status
    -- Select One --Pending ResolvedOther
57. Do you have an attorney in this matter?
    -- Select One --YesNo
59. Result, if known
60. Complaint number, if known
62. Attorney Name
63. Phone Number
65. Address
67. City
68. State
69. Zip Code
71. Email Address
73. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
75. Electronic Signature
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field