LEGAL REDRESS

Legal Redress/Civil & Human Rights Complaint Form

The Pasadena Branch NAACP’s Legal Redress Committee is designed to assist those unrepresented by legal counsel who have experienced racial bias, discrimination and /or retaliation in the private or public sector. The committee reviews, analyzes, researches and where appropriate, investigates each such claim. When the review process is completed, the complainant is notified of the committee’s conclusions and if and as appropriate, referred to legal counsel or advocate organizations with applicable specialty. For services rendered for each such complaint, the branch requests but does not require the complainant become a member of the branch or make a donation in an equivalent amount.

Please note that we will not process your application unless all questions are completed, along with a one-part summary of the alleged discrimination that occurred. Incomplete applications will not be investigated.

- Step 1 of 3
Your Information
Name *
First
Middle
Last
Address *
Address Line 1
City
State
Zip Code
Email *
Phone (Home) *
Phone (Work)
PLEASE NOTE THAT WE WILL NOT PROCESS YOUR APPLICATION UNLESS ALL QUESTIONS ARE COMPLETED, ALONG WITH A SUMMARY OF THE ALLEGED DISCRIMINATION THAT OCCURRED. INCOMPLETE APPLICATIONS WILL NOT BE INVESTIGATED. YOU MAY ADD ADDITIONAL INFORMATION.
Current member of NAACP Pasadena? *
Do you currently have an attorney? *
Attorney Name
First
Last
Attorney Address
Address Line 1
Address Line 2
City
State
Zip Code
Attorney Email *
Attorney Phone
Attorney Fax
Actions Taken
Select all that may apply. Please submit copies with complaint form.
Please list organization which you are filing complaint against: *
Place of business
Government agency
School district
Law enforcement
Other
Has a lawsuit been filed? *
When and where was the lawsuit filed?
Have you filed a complaint with the EEOC? *
When and which office was the complaint filed?
Have you filed a complaint with Fair Employment & Housing? *
When and where was the complaint filed?
Other actions taken
Details of the Discrimination
Type of discrimination *
Civil Rights Violation/Hate Crimes
Discrimination
Harassment
Housing
Racial Profiling
Retaliation
Other:
Other type of discrimination
How were you discriminated against? *
By who were you discriminated? - Include name(s), race and gender of each:
Name *
Race *
Gender *
Name
Race
Gender
Name
Race
Gender
Where did the discrimination take place? Cite location/address for each incident:
Address #1 *
Address Line 1
City
State
Zip Code
Is there another location/address?
Address #2
Address Line 1
City
State
Zip Code
Did anyone witness the discrimination that took place? *
Witness #1
First
Last
Phone
Address
Address Line 1
City
State
Zip Code
Is there another witness?
Witness #2 *
First
Last
Phone *
Address *
Address Line 1
City
State
Zip Code
What was the effect or impact of the discriminating behavior on you? *
To date, what actions have you taken so far? *
Have you filed a complaint with or notified any other organization or individual regarding this manner? *
Name *
Phone *
Address *
Address Line 1
City
State
Zip Code
What actions, if any, were taken in response to the complaint or notice of concern? *
Who took these actions?
When were these actions taken?
What would you like the NAACP Pasadena Branch to do for you regarding the discrimination complaint? *
RELEASE OF LIABILITY
I affirm that the statements that I have made above are accurate and tru to the best of my knowledge and belief. I hereby request the assistance of the NAACP Pasadena Branch in seeking a remedy to the situation described above. I hereby authorize the officers of the NAACP Pasadena Branch to have access to information and documents, which are relevant to my claim of discrimination described above.
I understand that once a referral has been made to a volunteer, community agency or private attorney, the NAACP Pasadena Branch WILL NOT BE RESPONSIBLE for handling this matter. I further understand that by signing this document, I am agreeing to HOLD the NAACP Pasadena Branch harmless for any and all damages arising as a result of my case being mishandled, negligently handled or improperly handled in any way.
Checkboxes *
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the below Terms of Acceptance. *
Terms of Acceptance: I, the applicant for this Legal Redress/Civil & Human Rights Complaint form, warrant the truthfulness of the information provided in this application.
Signature *
Date / Time *
NON-RETALIATION REQUIREMENTS

Section 704(a) of the Civil Rights Act of 1964, (as amended), Section 4 (d) of the Age Discrimination in Employment Act of 1967, (as amended), and various other civil rights laws make it an unlawful employment practice for an employer; employment agency; or labor organization: to discriminate against employees, applicants for employment, member or applicant for membership, because the employee, member or applicant has opposed an unlawful employment practice, made a charge, testified, assisted, or participated in any manner in an investigation, proceeding or hearing.

Important Notice
Please be advised that filing a discrimination complaint with the NAACP does not mean that the NAACP will be representing you in any legal matter. If you believe you have a discrimination claim, you must file a claim with the appropriate State or Federal agency in a timely manner. Failure to do so may prevent you from pursuing a claim in a court of law.

COMPLETION OF THIS FORM
Completing this form does NOT constitute filing an official complaint with a legal authority. At this time the NACP Pasadena Branch is ONLY seeking information to assist you concerning this complaint.
Name

Apr 13 2023

Legal Redress/Civil & Human Rights Complaint Form

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