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Civil Rights Complaint Form

Please Note: The Attorney General handles civil rights cases involving a pattern and practice of activity, matters involving a substantial portion of the population or an issue of public importance.

You may still be required to file a complaint with the Pennsylvania Human Relations Commission (PHRC) to preserve your individual rights in your case. By law, you must file a complaint with PHRC within 180 days of the act of alleged discrimination.

 

*indicates required field



 

Age Group

     
 


Your Information

Title

Your Name*

 

 

Address*

City*

State*

County*

Zip Code*

Daytime Phone Number*

Home Phone Number*

Email

 


Age Group

     

Title

Their Name*

 

 

Address*

City*

State*

County

Zip Code*

Daytime Phone Number

Home Phone Number

Email

 

Who is the complaint against?

 

Name of the entity or person*

Address

City

State*

County

Zip Code

Phone Number

Type of Business

Number of employees who work at the business named above

 

Legal Representation

Check the applicable boxes on why you feel your were discriminated against (treated differently.)  If you believe you were treated differently for a reason which is not listed, explain what you believe to be the reason.

 

 

 

 

 

 

 

 

 

 

  

  

  

 

If employment related, whom in management have you informed of your complaint?

What action was taken?

 

 

Do you know of any other individuals who have been treated the same or received similar treatment?

     

What happened to these individuals?.

 

 

Do you have any witnesses to verify or confirm your complaint?

     

Please explain if you have suffered any monetary loss or loss of benefits.

 

Provide the date(s) of incident(s)

 

Have you filed a complaint about this matter with any other agency?

     

If yes, please specify with one(s) and the date you filed, to the best of your recollection.

 

 

Have you filed any court actions in this matter?

     

If so, please specify in what court and the dated you filed, to the best  of your recollection.

 

If you are represented by an attorney, please provide your attorneys name, address and phone number:

 

What do you want to see happen as a result of your complaint?

 

Please explain your complaint including the details such as date, time and location. Describe the events in the order in which they happened. If you complaint is based on race, include the race of all the persons mentioned (including yourself.) If it is a gender complaint, supply the gender of all persons mentioned, etc..

 

 

PLEASE READ CAREFULLY

By completing and submitting this complaint form, I am adopting this as my online signature. I certify that the information provided is true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

PLEASE NOTE: YOU MAY NEED TO CONTACT A LAWYER SINCE THE ATTORNEY GENERAL CANNOT ACT AS YOUR PRIVATE LAWYER.

As a law enforcement agency, the primary function of the Attorney General is to represent the public at large by enforcing laws prohibiting acts of discrimination where there is a pattern or practice of unlawful activity. Your complaint does remain on file with our office and the information contained in it may be used to establish future violations of Pennsylvania law or other issues of general public importance.