HomeMy WebLinkAboutComplaint of Discrimination Form 2025Complaint of Discrimination Form under City Code Title 2
Local Commission # ICRC CP# --------------
City of Iowa City
410 E. Washington Street
Iowa City, Iowa 52240
Note: Please type or print
1.What is your name?
2.What are your pronouns?
3.What is your street address?
City __________________ State _____ Zip Code ___ _
4.Telephone number: ( __ )
5.What is your email address?
6.What is your date of birth?Sex: ____ _
7.Have you previously filed this complaint with any organization or agency? D Y D N
If yes, who _____________________________ _
8.On what basis(es) do you feel you have been discriminated against? Please check all that may
apply.
□Age □Color □Gender Identity
□Race □Creed □Religion
□Marital Status □Sex □Disability
□National Origin □Familial Status □Retaliation*
□Sexual Orientation □Presence of Absence of □Public Assistance Source
Dependents of Income
*Because I filed prior complaint or opposed a discriminatory practice.
9.Please check the area in which the discrimination occurred.
D Credit D Education D Employment D Public Accommodations
D Housing
10.What is the Full Legal Name of the Business or Company that discriminated against you?
11.What is the company's mailing address?
City: __________ _State: Iowa Zip Code:
County: __________ _Telephone Number: ( __ ) ___ _
12.What is the name of the person who discriminated against you?
13.What does that business/company do?
14.If the company named in #10 is owned by another company, what is the Full Legal Name of the
Owner Company? (Parent or Corporate Office of Company listed in #10.)
15.What is that company's street address?
City: ___________ _State: Iowa Zip Code:
Telephone Number: ( __ ) ___ _
16.Give approximate total number of full and part-time employees at all employer locations:
17.Identify the person at the company who discriminated against you?
Name: ______________________ _
Position/Title: ___________________ _
18.If you are claiming harassment, who harassed you?
Name: ______________________ _
Position/Title: ___________________ _
19.What is the last date that something discriminatory happened to you? _______ _
20. 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. Be sure to address each basis you checked
on page 1.
I certify under penalty of perjury and pursuant to the laws of the City of Iowa City, 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