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

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

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? *YesNo

Do you currently have an attorney? *YesNo

Attorney Name

First

Last

Attorney Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Attorney Email *

Attorney Phone

Attorney Fax

Next

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? *YesNo

When and where was the lawsuit filed?

Have you filed a complaint with the EEOC? *YesNo

When and which office was the complaint filed?

Have you filed a complaint with Fair Employment & Housing? *YesNo

When and where was the complaint filed?

Other actions taken

Next

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

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Is there another location/address?YesNo

Address #2

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Did anyone witness the discrimination that took place? *YesNo

Witness #1

First

Last

Phone

Address

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Is there another witness?YesNo

Witness #2 *

First

Last

Phone *

Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

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? *YesNo

Name *

Phone *

Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

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.

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