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IOWA CIVIL RIGHTS COMMISSION COMPLAINT FORM Complaint of Discrimination under Iowa Code Chapter216 "Iowa Civil Rights Act of 1965" Iowa Civil Rights Commission Grimes State Office Building 400 East 14th Street Des Moines, Iowa 50319-1004 (AGENCY USE ONLY) ICRC CP# ___________________________________ Local Commission # ________________________________ Equal Employment Opportunity Commission # _____________________________ NOTE: PLEASE TYPE OR PRINT (In Ink Only) 1. What is your legal name? _______________________________________________ 2. What is your street address? ____________________________________________ City: ________________________________ State: _____ Zip Code: _____________ 3. Telephone Number: (____) _____ - ________ 4. What is your date of birth? _______________ Sex: ______ Race: ________________ National Origin(ancestry): ___________________________ SS#: _______ - _______ - __________ (voluntary) 5. On what BASIS(ES)do you feel you have been discriminated against? (Please check) Age Physical Disability Color Race Creed Religion Marital Status Sex Mental Disability National Origin Pregnancy Retaliation* * Because I filed prior complaint or opposed a discriminatory practice 6. Please check the AREA in which the discrimination occurred. Credit Education Employment Public Accommodations 1 7. What is the FULL LEGAL NAME of the business or company that discriminated against you? ___________________________________________________________ What is that company's mailing address? _____________________________________ City:____________________________ State: IOWA* Zip Code: _____________ County: _________________________ Telephone Number: (____) _____ - _________ (*It must be located in Iowa; for employment cases, this is where you worked) 8. What does that business/company do? ____________________________________ 9. If the company named in # 7 is owned by another company, what is the FULL LEGAL NAME of the Owner Company? (Parent or Corporate Office of Company listed in #7) ______________________________________________________________________ What is that company's street address? ______________________________________ City: ________________________________ State: _____ Zip Code: _____________ Telephone Number: (____) _____ - _________ 10. Give approximate total number of full & part-time employees at ALL employer locations (VERY IMPORTANT): 4-14 15-19 20-100 101-200 201-500 500+ 11. Have you filed this complaint with any other Federal, State, or Local AntiDiscrimination Agency? Yes No If yes, what agency? _____________________________________________________ On what date did you file? ________________________________________________ 12. If this complaint can be cross-filed with the Equal Employment Opportunity Commission, the Iowa Civil Rights Commission will cross-file, unless you indicate in writing: "Don't cross-file." 13. Identify the person at the company who discriminated against you? Name: ________________________________________________________________ Position/Title: __________________________________________________________ 14. If you are claiming harassment, who harassed you? Name: ________________________________________________________________ Position/Title: __________________________________________________________ 2 15. What is the last date that something discriminatory happened to you? ___________ 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. I certify under penalty of perjury and pursuant to the laws of 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 Verification without notary authorized by Iowa Code section 622.1; 28 U.S.C. section 1746 Intaker Name _____________________ Phone ________________ (direct extension) 3