Today's Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Complainant Name * Individual Discriminated Against (if other than complainant): * Address * City / State / Zip Code * Email * Phone * Alleged Violation * Describe violation and City Department involved Resolution * What efforts have been made to resolve this complaint? First Date(s) of Occurrence * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Final Date(s) of Occurrence * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 If occurrence happened only once in a single day, put the same date in both boxes above. 2nd Date(s) of Occurrence (optional) * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Describe violation and City Department involved * What efforts have been made to resolve this complaint? * Please include a copy of supporting documentation (PDF or JPG Only) * ONLY PDF or JPG image files are accepted for supporting documentation uploads. Save files as PDF, scan to PDF or JPG, or provide a clear JPG picture of letters, e-mails, notes, etc.Files must be less than 5 MB.Allowed file types: jpg jpeg pdf doc docx. Has complaint been filed with State or Federal Agency * Yes No Not yet / In progress Electronic Signature Agreement * I agree By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. Electronic Signature * Leave this field blank
