Iowa-Nebraska NAACP Complaint Form

NAACP DISCRIMINATION COMPLAINT FORM
OUR MISSION

The mission of the National Association for the Advancement of Colored People is to ensure the political, educational, social, and economic equality of rights of all persons and to eliminate race-based discrimination.

VISION STATEMENT

The vision of the National Association for the Advancement of Colored People is to ensure a society in which all individuals have equal rights without discrimination based on race.
Date *

Month Day Year
First Name *
Last Name *
E-mail *
Home Phone Number *

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Street Address *
Street Address Line 2
City *
State *
Zip Code *
Date of incident or situation *

Month Day Year
Additional dates of incident or situation, please use full calendar dates
Are you a member of the NAACP *

Yes No
Which of the following NAACP branches/units is closest to you? *
Is this a complaint of discrimination? *

Yes No
What was the basis of the discrimination? *

Race, Culture or Color Other
If you answered "other" above, please specify.
Who or what entity do you believe discriminated against you? *
Please provide the contact person(s), title, complete address, email and phone number for the discriminating party *
Location of the incedent(s): List complete addresses. *
Please describe what happened being as detailed as possible. *
What effect has the incident(s) had on you? *
Do you have an attorney? *

Yes No
Have you filed a lawsuit or taken legal action? *

Yes No
If so, what is the outcome or current status of any lawsuit or legal action taken?
Have you filed complaint with another agency? *

Yes No
If so, please indicate which of the following agencies to which you have filed a complaint.

The discriminating entity's leadership or complaint process Equal Employment Opportunity Commission Department of Justice (DOJ) Department of Human Rights Department of Civil Rights Other
If so, what is the outcome or current status of claims filed with any agency above?
Please upload any documentation or files relevant to this complaint.
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What is your desired outcome? *
REFERRAL STATEMENT

The Iowa-Nebraska NAACP State Area Conference of Branches will seek to refer complaints to the appropriate local unit/branch for processing. In some cases which merit state level involvement, the Iowa-Nebraska NAACP retains the option to process the complaint directly or in concert with a local unit/branch.

IMPORTANT INFORMATION

Please be advised that filing a complaint of discrimination with the NAACP is considered a request for support and does not gaurantee that the NAACP will represent you in any matter, legal or otherwise. If you believe you have a discrimination claim, you also should file a claim with the appropriate state or federal agency in a timely manner. Failure to do so may prevent you from pursing a claim in a court of law.

RELEASE OF LIABILITY

I affirm that the statements that I have made above are accurate to the best of my knowledge and belief. I hereby request the assistance of the of the Iowa-Nebraska State Area Conference of Branches and/or it's appropriate units in seeking a remedy to the situation described above. I hereby authorize the officials of the NAACP to have access to information and documents which are relevant to my claim of discrimination described above.

I understand that by signing this document in the space below, I hold the NAACP harmless for any and all damages, legal claims or lawsuit arising from involvement.
Please sign this document by typing your full name *
Verify your signature by providing the last 4 digits of your social security number *
Thank you! The NAACP will be in touch with you shortly.
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NAACP DISCRIMINATION COMPLAINT FORM